I acknowledge that Wired BioHealth™ has clearly explained the details of services listed in this document and has also clearly explained that Wired BioHealth™ is not in any insurance network for Functional Medicine consulting, testing, nor treatment. The office and staff is not required to provide insurance statements, coding, billing statements, or documentation for the above named to seek insurance reimbursement. I understand that Wired BioHealth™ personnel act as consultants, not healthcare providers.
With my signature below, I give my consent to receive testing & biochemical pathway support plan recommendations and acknowledge that all of my concerns and questions have been addressed by the Wired BioHealth™ staff. I understand that the objectives of this program are to reduce my various chronic wellness complexities. I also understand that, given the nature of the chronicity of my condition(s), a complete return to wellness is not guaranteed. I understand that the laboratories utilized by Wired For Addiction® are CLIA approved. Wired BioHealth™ is not responsible for the outcome of my health.
I understand that Wired BioHealth™ consultants do not oversee my healthcare and will not write, overwrite, modify, nor discontinue prescriptions written by my psychiatrist or healthcare provider. With my signature below, I attest that the extent of Wired BioHealth™ virtual visits are to ensure compliance with recommendations specific to the Biochemical Pathway Support Plan Recommendations and Biomarker Evaluation Report, and do not determine medical care.
By signing this contract, I agree to the terms of service and fees of Wired BioHealth™. All testing & biochemical pathway support related fees will be paid in full prior to test kits being sent to the client. This contract does not include the cost of nutraceuticals, future testing, re-testing, nor virtual coaching visit(s). By signing this contract, I agree to provide 24 hours advanced notice for requesting to reschedule or cancel any Review of Findings Visit or Bi-Weekly Coaching Session. Failure to do so will result in a $75 charge for the missed visit. My desire to not utilize the Wired BioHealth™ test kits or to discontinue care and/or deviate from the Biochemical Pathway Support Plan Recommendations will not result in a refund, partial nor in full, and may result in client termination upon discovery.