Services to Be Provided
At Thrive Nutrition & Wellness, LLC, our goal is to help you achieve the highest state of health consistent with your own goals. Nutrition can serve as an excellent adjunct to a medical doctor’s treatment, but is not a substitute for that treatment. Services offered as a part of this consultation may include education about nutrition, personalized whole foods and dietary recommendations, meal plans, lifestyle modifications, herbs and nutritional supplement recommendations, such as but not limited to vitamins, minerals, herbs, amino acids and fatty acids. As a part of Medical Nutrition Therapy, I will perform a comprehensive nutrition assessment determining a nutrition diagnosis; plan and implement a nutrition intervention; and monitor and evaluate your progress.
Notice of Privacy Practices
All patient information is handled under the HIPPA Privacy Act. The privacy of your medical information, as described in the Health Insurance Portability and Accountability Act (HIPAA) Privacy Act, is important to Thrive Nutrition & Wellness, LLC. As a client, a record of your care and services will be created. This record is required to provide you with quality care and to comply with certain legal requirements. Thrive Nutrition & Wellness, LLC will not use or disclose your medical information for any purpose, without your specific written authorization. Any specific written authorization you provide may be revoked at any time by writing to Thrive Nutrition & Wellness, LLC at 4575 Main Street, Suite 3, Amherst, NY 14226. Thrive Nutrition & Wellness, LLC may use medical information about you to provide you with medical treatment or services and may disclose medical information about you to doctors, nurses, or other health care providers to assist them in treating you. Thrive Nutrition & Wellness, LLC may use and disclose your medical information for payment purposes. A bill or receipt may be sent to you or a third-party payer. The information on or accompanying the bill or receipt may include your medical information.
Client Rights and Responsibilities
It is your responsibility to fully disclose health information to Andrea. As service progresses, inform us of changes that occur to your treatment, including medication and health changes. You have the right to respectful, courteous care and can refuse to follow any or all recommendations provided as a result of this consultation. You have the right to choose another practitioner for any reason and to request that health information be disclosed to another practitioner or health care provider.
Fees and Charges
The initial consult fee is $150 for 90 minutes, and the follow-up consult fee is $100 for 60 minutes. 30-minute follow-up consults are $50 and available as treatment progresses. Additional time will be charged at a rate of $25 per 15 minutes. Payment for the consultation is due at the time services are rendered. Except in emergency situations, you will be charged for missed appointments without 24 hours notice. The fee for missed appointments is $50.00.
Supplement Safety
The historical record and modern research indicate that herbs and supplements most often used for healthcare have a good safety record. Similarly, confirmed cases of herb, nutrient and drug interactions are rare. However, adverse events can occur after using any active substance, including allergic response. Therefore it is imperative that you disclose to us: 1) all medications, supplements and herbs currently in use, 2) any liver or kidney disease (past or present), 3) any allergies, 4) if you plan to become pregnant or are currently pregnant or breastfeeding. It is important to stay within the dosage recommended. You are expected to inform your physicians of any nutritional supplement or herb use. Any suggestion that the effect of a drug is being altered by simultaneous use of an herb or nutritional supplement should be reported directly to all health professionals involved. It is also advisable to stop taking herbs and supplements 7 days before and after a surgical operation, and/or in the event of being prescribed a new medication.
Informed Consent
I am solely responsible for the decision to consult Thrive Nutrition & Wellness, LLC for Nutrition Counseling. I have reviewed this document, including safety of supplements, services to be provided, cancellation fees, my responsibilities as a client, and the Notice of Privacy Practices. I understand a nutritionist is not a physician and therefore cannot diagnose or treat disease, or prescribe drugs. If I have not already done so, I agree to consult a medical doctor for any serious or life-threatening disease conditions, either for myself, or someone under my guardianship. I have had the opportunity to ask questions regarding the proposed services, this consent form, and other pertinent information and have received satisfactory explanations. I understand that I am free to discontinue service(s) at any time.