SFM HCR Agreement

Holistic Clinical Review Agreement

Effective August 13, 2025
The following outlines the terms and conditions for the Holistic Clinical Review ("HCR") between the undersigned, (“Patient”) and Sparks Family Medicine, Ltd. (“SFM”). The Patient should review the information in this Agreement, including their rights and responsibilities, and retain a copy of this Agreement for future reference. Questions should be directed to the designated Program contact at SFM at 702-722-2200 or contact Contact@sparksfamilymedicine.com.

1. HCR Description

1.1. The HCR provides a holistic clinical review applying integrative and functional medicine (“I&FM”).

1.2.  The HCR is a one-time appointment for $495.

1.3.  The HCR is not covered by insurance.

1.4.  Additional costs and fees apply if the patient decides to establish with Dr. Sparks for the purpose of on-going care.

1.5 HCR payments are nonrefundable.

2.     Patient Responsibilities

2.1. Patient is responsible for completing the required paperwork prior to the HCR.

2.2. Payment for the HCR is due three days before the scheduled appointment.

2.3.  Patient is responsible for completing the HCR in a reasonable amount of time upon execution of this Agreement.

2.4 Patient acknowledges that the HCR is a one-time office visit and does not establish Dr. Sparks as the patient's primary care provider.



3.     Miscellaneous

3.1. The laws of the State of Nevada shall govern the validity of this Agreement, the construction of its terms and the interpretation of the rights and duties of the parties hereto.

3.2. Patient agrees to indemnify and hold harmless SFM from and against, but not limited to, all losses, claims, damages, errors, expenses, or liabilities arising from the administration of the HCR.

3.3.  This Agreement constitutes the entire agreement between the parties pertaining to the HCR between Patient and SFM and supersedes all prior or contemporaneous agreements, understandings, or negotiations of the parties.

3.4. Should any provision of this Agreement be held invalid, unenforceable, or unconstitutional by any governmental body or court of competent jurisdiction, such holding shall not diminish the validity or enforceability of any other provision hereof.

3.5.  Patient authorizes SFM and its third-party administrators and vendors to send email or text which may include the minimum necessary protected health information related to Patient status in the HCR and payments such as receipts, payment reminders and other communications that may include Patient name and payments received or due.
Date*

MonthDayYear
Date
Patient Name*

First NameMiddle Name/InitialLast Name
Patient Date of Birth*

MonthDayYear
Date
Responsible Party (if not the patient)

First NameMiddle Name/InitialLast Name
Relationship to Patient
Email*
example@example.com
I understand I will receive an email response at the provided email from Sparks Family Medicine, Ltd upon submission of this document with a PDF of the completed agreement attachment. I must use the password Patient#1 to open and save this attachment.
I understand and agree that this electronic signature is the legal equivalent of my signature in writing and I consent to be legally bound to this agreement.
Patient/Responsible Party Signature*

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Holistic Clinical Review Agreement