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This form is an important legal document. It explains the liability you are assuming by starting a wellness programme. It is critical that you read and understand it completely. After you have done so, please print your name, email address, and date in the spaces below.
Disclaimer
The nutrition advice given by Christina Martin DHNP, AIT is based on the information provided by the client/individual. The nutrition information given is meant only for the client /individual completing the forms/case history. It is the sole responsibility of the client/individual to provide complete and accurate information. Any misinformation or omitted information may affect the nutritional/assessment/advice. Any misrepresented information is solely the client’s/individual’s responsibility. Christina Martin DHNP, AIT provides nutrition consulting and recommendations only and is not licensed to diagnose a medical condition or illness. The client/individual must consult a physician for any medical advice.
I have volunteered to participate in a wellness programme and possible follow-ups under the direction of Christina Martin DHNP, AIT, which will include, but may not be limited to nutritional planning. In consideration of Christina Martin DHNP, AIT agreement to assist me, I do here and forever release and discharge and hereby hold harmless Christina Martin DHNP, AIT from any and all claims, demands, damages, rights of action or causes of action, present or future, arising out of or connected with my participation in any nutrition programme.
Assumption of Risk
I recognise that specific foods may create allergic and possible fatal reactions, most specifically products containing nuts. I have therefore specified any food allergies/sensitivities I am aware of on the “diet profile” case history/form. I am aware that specific foods may interact with certain medications. I have discussed the side effects of all of my medications with my doctor or pharmacist. I also understand the wellness information I receive will not take my medications into consideration unless I choose to list my medications on the “diet profile” form or during the case history. If I am pregnant or lactating, have high cholesterol, high blood pressure, high blood sugar, diabetes, renal disease, gastric by-pass surgery or any other medical condition that requires special dietary restrictions, I must receive permission/or discuss it with my physician before participating in the wellness programme, or may be advised to seek help from another health professional. I acknowledge and agree that no warranties or representations have been made to me regarding the results I will achieve from this wellness programme. I understand that results are individual and may vary.
Follow- up consultations and support
Support will be offered only for the current health issue to which the client has come to see Christina Martin DHNP, AIT about, and will be supported for a period of four weeks via a 5 minute telephone call or via email, any changes in health thereafter will not be supported within this four week window until the follow up. Four weekly clinic/Skype (Skype sessions must be prepaid) sessions will be recommended to the client to cover any changes in health or to allow adjustments to be made to their programme when necessary.
Booking and Cancellation policy
To ensure full utilisation of the therapist’s time and offer the best service to all patients the following appointment booking and cancelling procedures are in place from October 1 2014:
Upon booking an appointment with Christina Martin DHNP, AIT debit or credit card details will be taken and a case history form will be sent by email
Please note that the fees for a first consultation are:
£120 Ealing Clinic (will be £180 on the 1st June, to be in line with my current price structure)
£180 Wimpole Clinic
At the first visit, patients will also be required to fill in and sign the terms of business form.
Appointments can be cancelled using one of the following ways:
- By contacting Christina Martin DHNP, AIT directly – your call/SMS and /or email will be
acknowledged
By phone/SMS on 07956 843 575
By email at ecmartin@futurehealthmanagement.co.uk - By contacting the Ealing clinic on 020 8566 2223 if this is where your appointment is due to take place.
Cancellation fees
Over 48 hours prior to the appointment – no charge Between 48 hours and 24 hours – 50% of fee
Less than 24 hours – 100% of fee.
Price list of services – please note that there is a surcharge of 3% for credit card payments
|
Full case history at Wimpole clinic |
Duration: 1 hr to 1:15 min |
£180 |
|
Follow up at clinic/Skype call: sessions to be pre organised and pre paid before session |
Duration 30-45 min |
£95 |
|
Food intolerance Dietx /bioresonance test |
Duration: 1hr – 1:15 min |
Wimpole clinic £180 |
|
Biofeedback Full body scan with one remedy (if required) |
Duration: 1hr – 1hr 15 min Remedies will be included (for those who purchase a mobile biofeedback device) Device is sold separate |
Ealing clinic £180 Wimpole clinic £180 |
|
Metabolic Balance Program: weight loss and maintain it/hormonal balancing/menopausal symptoms/blood sugar disregulation and more… |
1.5 hrs initial Consultation Balance your metabolism for life! 6/30 min follow ups |
Package includes: initial blood test, tailored food plan and 7 coaching appointments. If you’d like further info please ask. |
|
Follow up Biofeedback therapy If you want to pay for each session individually |
45 min |
Wimpole clinic £95 |
|
BIOFEEDBACK PACKAGES |
||
|
Oberon 8 session package 5% discount Remedies are charged if not purchased as part of a package, at £3.50 per remedie. |
2-3 sessions a week recommended Package price £865 includes all remedies, 1 full body scan and 7 45 min follow ups |
5% when you purchase 8 sessions Re-scan’s are not included |
|
Oberon 12 session package 10% discount. |
2 or 3 sessions a week Package price £1,150 includes all remedies, 1 full body scan and 11 – 45 min follow ups |
10% discount when you purchase 12 sessions |
|
Oberon 24 session package 10% discount. |
2 or 3 sessions a week Package price £1,473 includes all remedies, 1 full body scan and 23 – 45 min follow ups |
10% discount when you purchase 24 sessions |
|
Health test offered by practitioner when required |
Cyrex, Regenerus labs and Genova Lab tests |
Lab tests are additional and will be discussed with you if required |
|
Supplements |
Mainly use Food state with no active yeast suitable for vegans (except vitamin D and Multi-vit) |
Supplemental program will be an additonal cost |
I have read and understood all of the above.
Signature of client/Individual Name: Email: Date: _________________________ __________________ _________________ ___________
——————————————————————————————————————————————————————- Future Health Management
Christina Martin DHNP, AIT, Clinical Naturopathic Consultant – The Ealing Chiropractic Clinic, 63 The Grove, Ealing W5 5LL Tel: 020 8991 1490 Mob: 07956 843 575 Email: ecmartin@futurehealthmanagement.co.uk