If you would like my service by phone or in person, please read and sign this document. You, not any insuring agency, are responsible for all charges incurred. Payments are due when services are rendered. It is up to you to seek reimbursement, if any, through your own insurance company. We will be happy to assist you in filling out any insurance forms.
Every unkempt appointment can prevent someone else from receiving services. If you must cancel an appointment, please do so promptly, but no later than one working day prior to your scheduled visit. Otherwise, you will be charged.
Various applications of nutrition and homeopathy rest on sound scientific principles, and background scientific information has been widely published. You will be given information which you should review to assist in any recommended nutritional program.
I shall not diagnose or treat any disease, since this is suitable only for physicians. My intention is only to help balance your body chemistry better, if that seems advisable. Should you be dissatisfied in any manner with the service provided by me or my staff, promptly bring it to my attention, so it can be properly discussed.
Phone Consultations: A phone consultation without an office visit does not imply a client/doctor or health provider relationship. It is important to realize that a phone consultation can only offer limited suggestions. I will look over any emails, saliva tests and blood chemistry tests during the call itself. Please have paper and pen ready to make notes. Please give me the following information in the phone consultation.
3. Symptoms: including emotional
4. Are the symptoms chronic or acute? – how long have you had each symptom?
5. Surgeries? What type and when did they occur?
6. Medications that you are currently using or have used during the past year.
If I have outlined a specific nutritional program, you can only expect desired results by following it. Individuals may vary greatly in their bodily biochemistry, and thus results of a nutritional program vary accordingly. I aim to help you to get good results, not being interested in spending your funds and our time without expectation of progress.
Please understand that I am not a physician of any kind, and any counsel given is strictly restricted to the nutritional, detoxification/cleansing, and homeopathic field.
Your nutritional program may include recommendation or dispensing of nutritional substances, such as foods, foods for dietary use as defined under federal law, nutritionally derived supplements, homeopathic remedies, and the like.
Again, I do not diagnose, treat disease or medical disorders, nor cure diseases or medical and emotional disorders. References to specific body functions or organs during counseling are not intended to diagnose or prescribe disease or medical disorders, but are only for your education. When you have read the above, and understand the nature of the services, am requested to render, kindly so indicate below.
Very truly yours,
Theresa Dale, Ph.D, CCN, NP
I have read the above statement and understand the nature of the services, which I have requested Theresa Dale to render. I understand I am responsible for payment of services.