• FDN® INTAKE FORM

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  • Please take your time and complete the following questions to the best of your ability. Your answers will be kept confidential. Don't hesitate to let us know if you have any questions. Should you wish to bring any additional information to our attention, please note it at the end of the form. Thank you.

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  • Teal Center FDN -Terms of Service Agreement

  • What we do and do not do

  • We obtain a set of laboratory test results from certified laboratories in the United States and provide you with a nutritional interpretation of those test results that you can use exclusively as an educational tool for personal health purposes.

    Your doctor may use the same test results to diagnose and treat disease, but we do not do this. The information we provide is not intended to, cannot, and should not be expected to be a substitute for a personal consultation with your own qualified doctor. We do not accept any liability for any failure to identify any medical condition or disease; this is not the purpose of our services.

    We may provide you with information relating to products that we believe might benefit you, but such information is not to be taken as an endorsement or recommendation. Some such products may not be available without a prescription, but we do not dispense or prescribe any prescription products. The information provided is intended for educational purposes only and should not be taken as professional medical advice or used as a substitute for medical care. We are not responsible for any adverse affects or consequences that may result, either directly or indirectly, from that information.

     

  • Consult your doctor

  • We are not qualified medical advisors and make no claims to be so. The information we provide should not be taken to be, and is not a substitute for, personal medical advice and instruction. You should not take any action based solely on our advice.

     

    You should consult your doctor:

    for any medical interpretation of your test results;
    on any matter relating to your health and well-being;
    before making any changes to your exercise or diet;
    before taking any nutritional, herbal, homeopathic or hormonal supplementation;
    before beginning any therapy.

  • Exclusion of warranties

  • We will provide our services to you with reasonable care and skill. But we make no other warranty, express or implied, with respect to those services. All other warranties are excluded to the maximum extent permitted by law.

    We make no warranty as to the accuracy of the laboratory test results we receive.

    We make no warranty, expressed or implied, as to the quality or effectiveness of any diagnosis, apparatus, treatment or product. In no event will we be liable for any physical or mental injury, or any negative side effects, that may arise from the use of any such diagnosis, apparatus, treatment or product.

    We believe that the information we provide, including that on our web sites, brochures, flyers and information packets, is accurate, but we cannot guarantee such accuracy. We therefore make no warranty as to the accuracy of that information, and it should not be relied upon as being correct, complete or accurate. It is your responsibility to verify such matters independently from primary sources of information and by taking specific professional advice.

     

  • Exclusion of liability

  • If you rely on, buy or use a product or therapy, you do so at your own risk. Each person is different, and the way someone reacts to a product or therapy may be significantly different from another. We cannot predict how you may react to any particular product or therapy.

    To the maximum extent permitted by law, we exclude:

    • any and all liability in contract, tort (including negligence), breach of statutory duty or otherwise for any direct, indirect, special, incidental, or consequential costs, losses, claims, damages, expenses or proceedings (including but not limited to loss of profits and wasted management time) incurred or suffered by you arising directly or indirectly out of or in connection with our services, including but not limited to any loss, damage or expense arising from any defect, error, imperfection, fault, mistake or inaccuracy with the information or advice we provide;
    • any and all liability for injury or loss arising out of the use of, or reliance on, the laboratory results and/or the dietary, supplement and lifestyle suggestions we may provide; any and all liability for injury or loss arising from any product or treatment you may choose to take; any and all liability for any failure to identify any medical condition or disease. You understand and agree that this is not the purpose of our services.
    • This is a comprehensive limitation of liability that applies to all damages of any kind, including (without limitation) compensatory, direct, indirect or consequential damages, loss of data, income or profit, loss of or damage to property and claims of third parties.
    • All material and information we may provide about products and therapies is provided solely for educational purposes and for use when discussing your health with your doctor. By providing you with such material and information, we do not necessarily endorse, recommend or promote any such product or therapy.
    • It is common practice for naturopaths, nutritionists and other non-licensed practitioners to collect your signature on a form such as this. By doing so you acknowledge and accept that we: are not medically qualified; are not a substitute for advice from a qualified doctor; recommend that you consult your doctor before making any changes to your diet or exercise regime or taking any dietary supplement; do not warrant the accuracy of any information provided; are not liable for any losses you may suffer by relying on our advice; do not recommend any particular product;
       
  • 2015 Functional Diagnostic Nutrition®

     

    By your signature below, and/or by instructing us to provide advice and services to you, you indicate your agreement to these terms.

    I have read and understood the above and I agree to it.

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  • Entering/typing name in the signature field above constitutes signing the document, confirming the signer agrees to the terms and conditions stated.

    2015 Functional Diagnostic Nutrition®

  • The Teal Center for Therapeutic Bodywork, Ltd.

    CLIENT AGREEMENT
  • I, *, give permission for my Teal Center practitioner to take notes about me, including health history/medical and/or personal information I choose to disclose. I understand that this information will be kept strictly confidential.

    I understand that, according to OSHA, massage and bodywork represents a MEDIUM RISK while Covid-19 exists. I acknowledge that social distancing during a bodywork session is not possible and I accept full responsibility for taking that risk. To mitigate the risk, I agree to wear a face covering at all times during my session.

    1. That massage therapy and/or acupuncture
    is for the purpose of stress reduction, relief from muscular tension and spasm, general relaxation and improvement of circulation and energy flow; is not a substitute for medical examination or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.

    2. That the massage therapists and/or acupuncturists 
    do not diagnose illness, disease or any other physical or mental disorder; do not prescribe medical treatment or pharmaceuticals; and do not perform any spinal manipulations.

    3. I agree that any and all appointment times are reserved exclusively for me and that I am responsible to remember them and to pay for appointments that I miss, cancel, or reschedule with less than 24 hours notice.

     If I need to reschedule due to illness, inclement weather, family emergencies, or Covid exposure, I agree to contact the Teal Center as soon as possible. I authorize The Teal Center to charge my credit card on file for 50% of the full amount of any appointment missed, cancelled, or rescheduled with less than 24 hours notice.

    I have stated all my known medical conditions and take it upon myself to keep the practitioner updated on my physical health.

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  • POLICIES

  • Welcome!

    And thank you for choosing The Teal Center Please READ and INITIAL each of the following:

  • * Appointments missed, cancelled or rescheduled with less than 24 hours notice will be charged in full. The only excusable reasons for late cancellation is for illness, inclement weather, family emergencies, and/or exposure to COVID. To avoid being charged for a missed appointment, we invite you to send a friend or family member in your place. Also, if we can fill appointments that are missed, cancelled or rescheduled with less than 24 hours notice the client will not be charged. It is your responsibility to remember your appointments. Confirmation emails are made 48 hours prior to the scheduled appointment.

  • * The Teal Center and its practitioners abide by the ethical standards of practice by their respective certification boards (NCBTMB and NCCAOM). All shall refrain from any behavior that sexualizes or appears to sexualize the client/therapist relationship. If such behavior occurs at any time, therapists are to terminate the session; payment will be made in full by the client and Center reserves the right to prohibit the client from returning to the Teal Center.

  • * If you have a cold or other contagious illness, please call us before your so we can check with your therapist to see if it is appropriate for you to come in.

  • *  In order to preserve a peaceful environment, we ask that you silence your cell phones while at The Teal Center.

  • * Tips are appreciated but never expected. If you wish to leave a gratuity for therapist we ask that you do so in cash or by check made directly to the therapist.

  • * If you move or change numbers, it is your responsibility to inform us. This is important information so we can reach you in case of any emergency or any necessary and unforeseen scheduling changes.

  • * The Teal Center does not submit insurance claims. We are happy to provide you with medical receipts, any treatment notes and payment history for your personal records. We will communicate directly with your insurer at their request only.

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