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)**
Authorization** I authorize
WELLNESS COUTURE, LLC to
(PATIENT / GUARDIAN NAME)
Period** All past, present, and future periods.
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.
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 Program with Viome | Stool Gut Intelligence Test - $369
• FOLLOWING A $250 MONTHLY MEMBERSHIP FOR 3 MONTHS
• 1 NUTRITION EVALUATION AND 6 NUTRITION FOLLOW-UP 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
• 1-Hour Nutrition Evaluation evaluating in-depth medical history from childbirth to present health status
• Remote via phone or video chat
• VIOME⎜STOOL GUT INTELLIGENCE TEST will be ordered and mailed out to you (5-7 business days)
NUTRITION FOLLOW-UP VISITS
• 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.
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
• Active Microbes
GUT HEALTH SIDES – ADD ON THE WELLNESS
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
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:
• 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
• 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)
• Colorectal cancer
• Diarrhea in infants and children spreading to adults
• High dietary intake of sugar, starches, and fungi
• Gall Stones
• Cystic Fibrosis
• Poor Diet
• Maldigestion or hypochlorhydria
• Upper GI Bleeds that cause Iron deficiency Anemia
• 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.
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.
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 August 6, 2020