I have sought the clinical and health care services of Vital Root Wellness – for my personal healthcare or for my child or children who are minors. I understand that this health practice uses some approaches and methods that are known as functional in nature. This may not be covered by my insurance plan or might not be generally accepted by mainstream medicine. The terms functional refer to therapies that may include, but are not limited to, dietary and nutritional supplement advice, certain dietary/exercise protocols to follow, reiki, meditation, and certain metabolic tests that are used for informational purposes. Furthermore, the information gained from laboratory and evaluation tests may be interpreted differently from mainstream medical doctors. Approaches for improving general health and nutrition may be based upon the tests/evaluations and philosophies of functional medicine and may or may not be consistent with mainstream medical tests/evaluations and philosophies. Although prescriptions and over-the-counter medications are used when your physician deems it necessary, foods, vitamins, minerals, enzymes, herbs, and other nutritional approaches may also be chosen as therapy or as adjunctive to medical therapies. It is your responsibility to ensure you inform your medical doctor of all supplements/diets you will be partaking in so that he/she can make sure there are no contraindications to your medicine. In addition to recommending oral nutritional supplements it is not uncommon that our office might use products/approaches that are not FDA (Food and Drug Administration) approved or evaluated for any condition though are in compliance and permitted to be used pursuant to the federal Dietary Supplement Health and Education Act of 1994. Our nutrition programs are exclusively ours, not affiliated with a local hospital. As a result, WE STRONGLY RECOMMEND THAT IN ADDITION TO OUR SERVICE YOU MAINTAIN A RELATIONSHIP WITH ONE OR MORE PHYSICIANS QUALIFIED TO CARE FOR YOUR INDIVIDUAL HEALTH CONDITIONS. For example, in the case of children we advise you seek the advice of a pediatrician; if you have cardiovascular disease consult a cardiologist; and if you have cancer consult with an oncologist; if you have any other degenerative conditions like, Diabetes, Lupus, Lou Gehrig’s disease (ALS), Multiple Sclerosis, or any other auto-immune disease seek the advice from the appropriate medical professional. We often refer clients to these and other healthcare professionals when it is deemed necessary. These physicians can provide you and your family with emergency care if hospitalization is needed and ongoing follow-up care. Our practice does not work with clients who have signs of eating disorders (ED). We do maintain relationships with mental health care providers and will refer out to them in the instance that we recognize signs of ED. We are happy to communicate and cooperate with your doctor(s) regarding your medical condition(s), options or any other health related issues. As with many health-related services, there are certain potential complications which may arise during the receipt of these services. Those complications range from discomfort through serious health concerns requiring emergency medical care. The probability of these complications are rare but you are being made aware of the full range of possibilities that may occur and assume the risk of proceeding with care by signing this agreement. Our office and its employees make no representations, claims, or guarantees regarding the efficacy of our recommendations. The protocols we recommend are based upon a combination of our clinical experience and knowledge of scientific and medical literature. With this information, individualized protocols may be offered and applied as either adjunctive or primary protocols for certain conditions. The undersigned is also expressly notified that some personnel providing training and nutritional services are engaged in the process of obtaining certification as a CNS-Certified nutrition specialist and has already obtained a Master’s of Science degree in these areas. Such personnel, upon request, will be identified and the status of their certification, education and training provided upon request. If no such request is made, it is assumed that the undersigned consents to the provision of these services by these individuals. The information you have provided/will provide via questionnaires, phone, email, in-person, or by any other means of communication is accurate to the best of your knowledge. Means of communication between practitioner and client are not currently covered by HIPAA. The education you will receive is personal and applies to you only. This same advice may be ineffective or even harmful when applied to other people with different background. You must communicate to any changes in my medical prescriptions or treatments for the duration of my program. You must inform Vital Root Wellness promptly if any of my new changes in diet or lifestyle start to cause adverse effects. You understand that the education you shall receive will not be enough to achieve your lifestyle goals unless you follow it diligently and commit to it fully. You understand any changes in your lifestyle may produce effects in your body, energy, health, and condition that are gradual in nature – not instantaneous. You understand that, although Vital Root Wellness will endeavor to help you achieve lifestyle goals to the extent possible, the possibility exists you may not fully attain your goals due to factors outside the control of Vital Root Wellness. Results are not guaranteed or typical. You understand and agree to all of the following: that any dispute arising from this agreement whether from my receipt of services, participation, or any other reason, which arises between Vital Root Wellness and yourself will be governed under New York law, without regard to conflicts of laws principles, and must be brought before a New York state or federal court sitting within New York County. Our office makes available nutritional supplements and other health related products. You are in no way obligated to purchase these products from our office or any other specific location or company. You may freely choose to purchase such products from any source(s) you wish. Vital Root Wellness and its employees may profit from the sale of supplements and other products we make available to our clients. Our services such as nutritional consults, reiki, mediations, exercise programs, dietary protocols and testing (blood/urine/saliva) are often not considered by insurance companies to be necessary or a “covered service” and, therefore, reimbursable, based upon their own criteria. Our office does not accept insurance. By signing this form you accept full financial responsibility for all services; including consultations, blood/saliva/urine and other laboratory tests and procedures. SIGNATURE ON FILE: By signing here you agree, in sound mind, to release Jessica Coghill of any or all liabilities from illness or injury arise from the use of any and all workout, reiki, meditation, supplements, nutrition and stretching protocol. You understand that there are no refunds for wellness and/or nutrition plans. Please read these terms carefully. By signing this informed consent, you agree to hold harmless Vital Root Wellness, it’s owners, employees and contractors from all professional and personal liability, negligence, or other legal liability. You agree to be responsible for all legal costs and fees that may result from action(s) on your part or on the part of your representative(s) against us. If a legal case is brought against us, you agree that we shall be judged by the standard principles of functional medicine and not the standards and principles of consensus of conventional/allopathic medicine. You have the right to have this consent reviewed by your lawyer before accepting any services from our office and we suggest that you exercise this right. Your signature verifies and affirms that you have not been told to discontinue treatments with any other medical specialists or other health care providers. Your signature is being given prior to rendering any services, advice, and/or recommendations whatsoever from Vital Root Wellness. Vital Root Wellness also recommends that you get medical clearance from your MD before you partake in any of the wellness modalities we might suggest. It is the responsibility of the client to follow-up with our office for results of all testing and laboratory procedures. It should not be assumed on the part of the client that if they are not contacted by Vital Root Wellness, or its employees, or if the client does not schedule or keep consultation, that test results are normal (or without abnormalities), and may not require further follow ups or advice. Health/medical recommendations and/or possible referral and additional follow-up may be warranted based upon laboratory testing and evaluations. The client is further notified that some tests, or all, may not be covered by their insurance company. The client assumes full responsibility for the costs of non-covered tests. Vital Root Wellness does not assume responsibility for costs of non-covered tests. Vital Root Wellness does not assume full responsibility for costs incurred regarding non-covered and/or potentially-covered services, including procedures, lab tests (blood, urine, saliva, etc.) and our consultations. Vital Root Wellness does not allow their sessions with any client to be recorded on any kind of device, if a client wants to record a session Vital Root Wellness has to give its consent. By entering your signature below you are acknowledging that you have read this entire agreement, understand all terms, verbiage (language) and concepts herein, and agree to proceed with care. You also affirm that you have discussed the services to be provided, the risks and benefits of said services, and the alternatives to these services, with an authorized representative of Vital Root Wellness and have had all of your questions answered to your satisfaction. By signing below you agree that you have weighed the risks and benefits of proceeding with the services and have decided that it is in your best interest to obtain the services proposed. Having been informed of the potential risks, I hereby give my consent or the consent of the minor to which I am legal guardian for said services. I understand this consent agreement and have executed it freely and willingly. VITAL ROOT WELLNESS REQUIRES 24 HOURS NOTICE UPON CANCELING AN APPOINTMENT. IF PRIOR NOTICE IS NOT GIVEN, YOU WILL BE CHARGED THE FEE ASSOCIATED WITH THE SCHEDULED APPOINTMENT. SIGNING THIS AGREEMENT CONFIRMS YOUR CONSENT TO THESE TERMS.