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WELLNESS COUTURE believes “Your HEALTH is Your WEALTH”

Differing from conventional medicine and treatment, WELLNESS COUTURE calls attention to the root of the problem by a process of integrative personal care and tailoring to ensure comprehensive and preventative therapeutics. Our professional goal is to encourage clients to become knowledgeable about and responsible for their own health, and to help them to reach an optimal level of wellness. WELLNESS COUTURE is designed to improve your health, but is not designed to treat any specific disease or medical condition. Reaching the goal of optimal health and wellness, absent of other non-nutritional complicating factors, requires a sincere commitment from you, including lifestyle changes and a positive attitude. We will evaluate your nutritional and/or fitness needs and make recommendations of dietary changes, nutritional supplements, and/or fitness planning as indicated. Everyone is biologically unique;therefore, we cannot guarantee any specific result from my recommendations. This is your Consent and Understanding (HIPPA Form) and Financial Policy form, which is to be read and signed prior to your first Wellness Couture visit. All information will be kept confidential. Your feedback of your experience with our services will help WELLNESS COUTURE, LLCdesign an provide the upmost quality of care and comprehensive program that meets your individual needs.

Thank you for choosing WELLNESS COUTURE, LLC.

BEST,

Dr. Cynthia Barrett, PT, DPT, CSCS, CNS FOUNDER & CEO

CONSENT AND UNDERSTANDING

This consent is required by the Health Insurance Portability and Accountability Act of 1996 to inform you of your rights for privacy with respect to your healthcare information.

HIPAA Privacy Authorization Form

**Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)**

**1.
Authorization** I authorize
 WELLNESS COUTURE, LLC to 
use
 and
 disclose 
the 
protected 
health 
information 
described
 below
 to:

 

 

(PATIENT / GUARDIAN NAME)

**2. Effective 
Period** All past, present, and future periods.

**3.
Extent 
of
 Authorization** 
I 
authorize 
the 
release 
of
 my
 complete 
health 
record.

4.  This 
medical
 information
 may 
be 
used 
by 
the 
person 
I
 authorize 
to 
receive
 this
 information 
for 
medical
 treatment 
or 
consultation,
 billing 
or 
claims 
payment, 
or
 other 
purposes 
as 
I 
may 
direct.

5.  I 
understand
 that 
I 
have
 the 
right 
to 
revoke
 this 
authorization,
 in
 writing,
 at 
any 
time.  
I 
understand 
that 
our vocation 
is 
not 
effective
 to
 the 
extent 
that 
any
 person
 or entity
 has 
already 
acted 
in 
reliance
 on 
my
 authorization 
or 
if 
my
 authorization
 was 
obtained
 as 
a 
condition 
of
 obtaining 
insurance
 coverage
 and
 the
 insurer 
has
 a 
legal
 right
 to
 contest 
a
 claim.

6.  I
 understand 
that
 my
 treatment, 
payment, 
enrollment, 
or
 eligibility 
for
 benefits
 will
 not 
be 
conditioned 
on 
whether 
I 
sign
 this 
authorization.

7.
 I 
understand 
that 
information 
used
 or
 disclosed 
pursuant 
to
 this
 authorization 
may
 be 
disclosed 
by
 the 
recipient 
and
 may
 no
 longer
 be
 protected
 by
 federal
 or state 
law.

 

 

Consent for Care:

I, with my signature, authorize WELLNESS COUTURE, LLC, and any employee working under the direction of Dr. Cynthia Barrett, PT, DPT, CSCS, CNS to provide medical care for me, or to this patient for which I am the legal guardian.  This medical care may include services and supplies related to my health (or the identified person) and may include (but is not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of herbal, devices, equipment or other items required and in accordance with referrals from healthcare professionals.  This consent includes contact and discussion with other healthcare professionals for care and treatment.

 

Appointments and Cancellation Policy:

I agree to keep all scheduled appointments and be on time. If I cannot attend a scheduled session, I will contact WELLNESS COUTURE to cancel and/or reschedule.

NOTE:  If a phone message or conversation is not received within 24 hours before the scheduled appointment time, you will lose that session.  I understand if I am more than 30 minutes late, I forfeit my session.

NOTE: The card you provide will be charged $250 the first of every month for your membership.

 

Financial Policy:

We appreciate you choosing us for your health care.  We will adhere to the following financial policy in order to consistently deliver high quality care and services.  The patient/responsible party assumes responsibility to ensure that the financial obligation is fulfilled for the health care services received:

●      I understand that I am responsible for all fees for services; due at the time the service is provided.  Forms of accepted payment include cash or check, and Health Savings Account/Flexible Spending Account. I will make payment when checking in for my appointment. It is my responsibility to verify applicable coverage when using a Health Savings Account/Flexible Spending Account prior to receiving the services.  I consent to assign all payments for services directly to this practice.  I further consent to the use for any practice operational needs as identified by WELLNESS COUTURE, LLC.

 

● I authorize Wellness Couture to charge the credit card indicated in this authorization form according to the terms outlined above.  This payment authorization is for the goods/services described below, for the amount indicated below, and valid for additional orders (recommended supplements, products, etc). by Wellness Couture, LLC. I certify that I am an authorized user of this credit card and that I will not dispute the payment with my credit card company; so long as the transaction corresponds to the terms indicated in this form.

 

NUTRITION SERVICES 

Nutrition Program with Test GI-Map Stool Test | Gastrointestinal Microbial Assay Plus - $695

• Following a $250 monthly membership for 3 months

• 1 Nutrition eval and 6 nutrition followup visits 

 

 

DESCRIPTION OF NUTRITION SERVICES


1 Nutrition Evaluation followed by 6 subsequent Nutrition Follow-up visits to provide a comprehensive individualized custom plan of action to reach individual nutrition goals


NUTRITION EVAUALTION

Visit #1

• 1-Hour Nutrition Evaluation  evaluating in-depth medical history from childbirth to present health status 

• Remote via phone or video chat

• GI-MAP STOOL TEST | GASTROINTESTINAL MICROBIAL ASSAY PLUS will be ordered and mailed out to you (5-7 business days)

 

NUTRITION FOLLOW-UP VISITS 

Visit #2-7

• 1-Hour Nutrition Follow-up session to review of test results along with 30-Minute subsequent Follow-up visits

• A Comprehensive nutrition plan is provided formulating a plan specific to your makeup tailoring the program for your body as it is not a 1-size-fits-all approach: 

1. Providing realistic plan of care with seamless integration into and without compromising current lifestyle
2. Executing the Nutrition plan and measuring against your goals
3. Tracking your progress and checking in 2x a month
4. Each visit adjusting the plan as necessary

• Remote via phone or video chat

Sessions expire after the end of your 3 month program

Additional Specialty Tests to evaluate your individual microbiome may also be recommended based upon clinical presentation.

STOOL PANEL

GI-MAP | GASTROINTESTINAL MICROBIAL ASSAY PLUS - $695

How can you OPTIMIZE your GUT MICROBIOME by unlocking your Gene Mapping through GI-MAP TESTING?

Gastrointestinal Microbial Assay Plus or the GI-MAP™ test is an innovative clinical tool that measures gastrointestinal microbiota DNA from a single stool sample with state of the art, quantitative polymerase chain reaction (qPCR or real-time PCR) technology.  Since the GI-MAP is a DNA-based test, results reflect the levels of pathogenic strains carrying the toxin genes, not the levels of any toxins that may be produced.

 

The GI-MAP was designed to detect microbes that may be disturbing normal microbial balance or contributing to illness as well as indicators such as:

• Digestion
• Absorption
• Inflammation 
• Immune function

What does the GI-MAP Test?

The GI-MAP tests for PATHOGENS known to cause intestinal gastroenteritis:

• Parasitic Pathogens
• Viral Pathogens
• Normal Commensal Bacteria 
• Opportunistic Bacteria 
• Fungi/Yeast
• Viruses
• Parasites 
• Worms
• Intestinal Health Markers of Digestion/Malabsorption
• Crucial GI Markers of Digestion/Malabsorption
• Antibiotic Resistance Genes

 

Who is a GOOD CANDIDATE for GI-MAP Testing?

GI-MAP Testing may be indicated if you suffer from or have a family history of one of the following: 

• Intestinal infections and proinflammatory dysbiosis 
• Food allergens and/or sensitivities
• Toxins and certain drugs (e.g., non-steroidal antiinflammatory drugs [NSAIDs], Antibiotics)
• Fecal contamination of food, water and liquids (eggs, poultry, undercooked meat, raw shellfish, raw milk/dairy products, vegetables, and unpasteurized juice) 
• Swimming in Contaminated water (Ocean, lakes, streams, ponds, pools)
• Skin Contact with Contaminated Soil 
• Pets - Cats and Dogs 
• Sexual contact 
• Inflammatory bowel disease
• Impaired Immune function 
• Bloody diarrhea, Hemorrhagic colitis, may progress to hemolytic uremic syndrome (HUS)
• Polyps 
• Diverticulitis
• Colorectal cancer
• Diarrhea in infants and children spreading to adults 
• High dietary intake of sugar, starches, and fungi 
• Gall Stones
• Cystic Fibrosis
• Vegetarians/Vegans
• Poor Diet
• Dysbiosis
• Maldigestion or hypochlorhydria
• Celiac 
• Upper GI Bleeds that cause Iron deficiency Anemia

 

GUT HEALTH SIDES – ADD ON THE WELLNESS

STOOL PANEL 

VIOME | GUT INTELLIGENCE TEST - $369

NOTE: TEST IS NOT AVAILABLE FOR NY STATE RESIDENTS TO ORDER IN OR MAIL OUT FROM NY STATE

The Viome Gut Intelligence Test is a Stool Test that captures everything that is happening in the gut microbiome using metatranscriptomic sequencing technology allows us to see every microorganism in your gut microbiome and analyze the activity of these microorganisms. By analyzing the genes that microbes express, we can identify which metabolites they produce – in other words, we can determine their role in your body’s ecosystem.

 

Viome Gut Intelligence Test provides the following individualized recommendations to fine-tune the function of their gut microbiome to minimize production of harmful metabolites and maximize the production of beneficial ones.  Test results reveal:

• Foods to Avoid and Minimize
• Superfoods
• Supplements
• Active Microbes

 

URINE PANEL

ORGANIX COMPREHENSIVE TEST - $595

Organic acids are metabolic intermediates that are produced in pathways of central energy production, detoxification, neurotransmitter breakdown, or intestinal microbial activity. Marked accumulation of specific organic acids detected in urine often signals a metabolic inhibition or block. The metabolic block may be due to a nutrient deficiency, an inherited enzyme deficit, toxic build-up or drug effect. Several of the biomarkers are markers of intestinal bacterial or yeast overgrowth.

 

The Organix® Comprehensive nutritional test profile provides vital patient information from a single urine specimen. This organic acids nutritional test is valuable for determining:

• Functional vitamin and mineral status
• Amino acid insufficiencies like carnitine and NAC
• Oxidative damage and antioxidant need
• Phase I & Phase II detoxification capacity
• Functional B-complex vitamin need
• Neurotransmitter metabolites
• Mitochondrial energy production
• Methylation sufficiency
• Lipoic acid and CoQ10 status
• Markers for bacterial and yeast overgrowth


• Must have Nutrition Membership to purchase Urine Testing services

 

GENETIC PANEL 

• MINI DIET DX ⎜ NUTRIGENOMIC -  $595

Everyone’s optimal diet is different and is based on their genes and current state of health. In this mini panel, we address questions such as: 

• Do you have issues with oxalate, salicylate, histamine, or sulfur metabolism? 
• Are you predisposed to heart disease or genetically high cholesterol and does that impact how much fat you should eat? 
• Would a high fat diet work well for weight loss or might it result in an increased risk for cardiovascular disease? 
• Are you able to consume diary products without increasing inflammation? 

 

The answers to these questions will help you begin to learn what is the best diet for you by uncovering inflammatory triggers in your food and providing lifestyle, supplement and diet changes that will significantly improve your health. 

 

OTHER TEST

IMMUNOLYTICS | MOLD TEST KIT - $283+

ImmunoLytics is the leading mycology lab used by doctors, pharmacists, and environmental specialists to analyze mold samples and help evaluate patients’ homes, school and work environments, a vital step toward a healthier life. 

ImmunoLytics lab utilizes cutting-edge mold analysis focusing on mold identification and mold counts.  The information our mold test kits and analysis can provide is essential for helping determine if contamination is present and what steps must be taken if it is. 

ImmunoLytics complete analysis can tell homeowners, doctors or others exactly what they are dealing with in regard to mold type. This is vital for putting into place the proper remediation protocol. 

 

 

Agreement 

I have read and understand the Consent and Financial Policy stated above and agree to accept full responsibility as described above.

 I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. 

I Agree
Patient / Guardian                                               March 29, 2020

 

 

   

 

 

 

 

 

 

 

 

 

 

 

 

First Patient Name

First Name*

Middle Name

Last Name*

Phone*
First Patient Date of Birth*
First Patient Signature*
Second Patient Name

First Name*

Middle Name

Last Name*
Second Patient Date of Birth*
Third Patient Name

First Name*

Middle Name

Last Name*
Third Patient Date of Birth*
Fourth Patient Name

First Name*

Middle Name

Last Name*
Fourth Patient Date of Birth*
Fifth Patient Name

First Name*

Middle Name

Last Name*
Fifth Patient Date of Birth*
Sixth Patient Name

First Name*

Middle Name

Last Name*
Sixth Patient Date of Birth*
Seventh Patient Name

First Name*

Middle Name

Last Name*
Seventh Patient Date of Birth*
Eighth Patient Name

First Name*

Middle Name

Last Name*
Eighth Patient Date of Birth*
Ninth Patient Name

First Name*

Middle Name

Last Name*
Ninth Patient Date of Birth*
Tenth Patient Name

First Name*

Middle Name

Last Name*
Tenth Patient Date of Birth*
Patient Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Billing Information
Card Type
Visa
Master Card
Discover
Amex

Card Number

Name of Cardholder

Exp. Date

Security Code

Address

Apartment, suite, unit, building, floor, ect

City

State

Zip
Insurance

HSA⎜HEALTH SAVINGS ACCOUNT / FSA⎜FLEXIBLE SPENDING ACCOUNT


Card Number

Name On Card

Exp. Date

Security Code
Employer Details

Occupation

Employer

Employer Address

Employer Zip Code

Employer State
Patient Info:

Patient name (as appears on photo ID)
Do you know your Blood Type?

If you do, please enter it here. If you don't, please put unknown.
Social Media Authorization

Authorization: I authorize the use and disclosure of my name, photographic/video images, and/or testimonial for marketing purposes by WELLNESS COUTURE, LLC. I understand that the information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations. 

Purpose: The photographic/video images, and/or testimonial will be used for: Social Media and/or Advertising. 

Revocability: I understand that I may revoke this authorization at any time, but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive. This authorization expires 99 years from date signed. No Treatment Conditions: I understand that the practice cannot condition treatment on whether or not I sign this authorization.

No
Yes
Which Plan Would You Like To Start?
NUTRITION
• NUTRITION PROGRAM WITH GI-MAP STOOL TEST⎜GASTROINTESTINAL MICROBIAL ASSAY PLUS - $695 + MEMBERSHIP $250 A MONTH FOR 3 MONTHS
URINE PANEL
ORGANIX COMPREHENSIVE PROFILE - $595
GENETICS PANEL
MINI DIET DX ⎜ NUTRIGENOMIC - $595
STOOL PANELS
VIOME⎜GUT INTELLIGENCE TEST - $369
ENVIRONMENTAL MOLD PANEL
• IMMUNOLYTICS⎜MOLD TEST KIT - $283+

Notes:

Total
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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