Comprehensive Health Consent & Billing Agreement

Scope of Integrative Health Services

Integrative health consultations are provided by a licensed pharmacist for wellness and educational purposes. These services do not replace medical diagnosis, emergency care, or treatment by a physician.

Complete Follow-Up Consultation - $275 Additional Consultations & Communication - $150/hour ($50 minimum for calls, texts, or emails)

This is a cash-based practice. Insurance is not billed. Payment is due at the time of service. Labs and supplements are not included unless stated.

I understand the scope, limitations, and financial responsibility for integrative health services.

Comprehensive Integrative Health Intake

Section 1: Patient Information

Section 2: Primary Concerns (Detailed)

Secondary concerns

Section 3: Past Medical History

Section 5: Medications, Supplements & Therapies

Section 6: Nutrition Assessment

Section 9: Stress, Mental & Emotional Health

Section 10: Hormonal Health (if applicable)

Section 11: Environmental & Lifestyle Factors

Section 12: Functional Review of Systems (0 = none, 5 = severe)

 

Section 13: Goals & Commitment

Section 14: Consent & Acknowledgement

I understand integrative health care is individualized and outcomes vary.