Chief complaint – What is the reason you are seeking care? Please give a detailed account of your medical history. Be sure to include any surgeries, diseases, hospitalizations, diagnoses, or major medical incidents. Are you currently taking any prescription medications? If so, please list. Are you currently taking any OTC supplements or drugs? If so, please list. Do you have any allergies or sensitivities that might impact your ability to consume specific foods or supplements? Are you on any medications that might impact your ability to consume specific foods or supplements?
I understand that participation in the Well World Cleanse is intended for otherwise healthy individuals who interested in exploring the role of nutrition in health. After an initial intake, the programs are entirely self-directed. If you have questions or concerns, follow-up consultations are always available by appointment and for an extra charge.
Individuals with underlying health conditions should always seek the advice of a medical professional before embarking on any new program or protocol. Release Agreement:
I am requesting the following services
30 minute nutritional consultation ($150) – NEW CLIENTS
$50/month access charge- ALL CLIENTS WHO WISH TO ACCESS THE WELL WORLD APP
Protocols and pricing might vary slightly depending upon individual needs.
I Agree to the Following:
1) I understand that I am advised by CornerStone Integrative Care LLC DBA Althea Health and Wellness that it is necessary to communicate my intentions to participate in this program with my physician, describing its various components with my physician, and will obtain permission from said physician prior to receiving these services. If my physician is of the opinion that participation in this program offered by CornerStone Integrative Care LLC DBA Althea Health and Wellness will aggravate any symptoms, illnesses or disorders which my child/self may have, or will it be harmful, injurious or detrimental to the health, safety or well-being of my child/self I will not participate in this program.
2) I warrant and represent that my child/self is (are) in good physical and mental health and have no ailment, disability or impairment which might prevent him/her/myself from receiving these services or which might be aggravated or activated by such services.
3) I am aware that each human body is different structurally and bio-chemically and will react differently to the services provided. Accordingly, there is no certainty or predictability as to how my, or my child's body, might react. I acknowledge that I am participating in this program of my own free will. CornerStone Integrative Care LLC DBA Althea Health and Wellness has not made any claim, promise or guarantee regarding the effectiveness, usefulness, performance or safety of this program.
4) I understand that the services provided by CornerStone Integrative Care LLC DBA Althea Health and Wellness are not a substitute or alternative to medical care. I retain the responsibility for ensuring that my child/self is under the regular and continuous supervision of a licensed physician.
5) I am aware that under no circumstance will the services provided by CornerStone Integrative Care LLC DBA Althea Health and Wellness diagnose. treat, operate on or prescribe for any disease, pain, injury, or physical condition. Only a licensed physician may engage in such activities.
6) Costs for the services, therapy, supplements of the program have been disclosed to me. I understand that all prices are subject to change, I have been notified that any costs involved by CornerStone Integrative Care LLC DBA Althea Health and Wellness will NOT BE COVERED by medical insurance and that no medical or insurance coding will be provided on any invoices.
7) CornerStone Integrative Care LLC DBA Althea Health and Wellness will accept vitamin/supplement returns within 30 DAYS of purchase provided they are unopened and in good condition. However, IMPRINTED ITEMS CANNOT BE RETURNED.
8) I understand that full payment is due at the time of service, unless other arrangements have been made. We accept cash, checks, Visa, Mastercard, Venmo, PayPal and Zelle.
9) 24 Hour cancellation notice must be made in order to not be charged for the appointment. Exceptions can be made for emergencies only. A 50% cancellation fee will be applied for missed appointments.
10) I am aware that these services require that I provide confidential health information regarding my child/self to CornerStone Integrative Care LLC DBA Althea Health and Wellness and any affiliated health care practitioners within the practice.
11) I acknowledge that I have evaluated the advisability of my child's/own participation in the program provided by CornerStone Integrative Care LLC. DBA Althea Health and Wellness. I, in turn, take full responsibility for the physical, mental and emotional transformations attained as a result of such participation. In consideration of CornerStone Integrative Care LLC DBA Althea Health and Wellness's consent to allow my child/self to participate in the program, I hereby agree for myself, my heirs, and assigns to hold CornerStone Integrative Care LLC DBA Althea Health and Wellness harmless for any and all liability arising out of my child's/own participation in the program or receipt of any services. I take full responsibility for any and all injuries or losses, and freely, knowingly, and voluntarily agree to assume all risks involved, if any, during the program.