Client Agreement- Sarah Mathis Wellness LLC

 

Client Agreement

Date Effective:  June 11, 2024

 

CLIENT AGREEMENT – SARAH MATHIS WELLNESS LLC 

This is a legal agreement between [SARAH MATHIS WELLNESS LLC] (“Company”) and you (“Client”).

In order to best serve you, the Client Acceptance Policy should be carefully reviewed. It is our opinion that you should be well informed on our expectations and recommendations. To prevent any misunderstandings or confusion on what to expect, we would appreciate that you read the below steps and provide your signature. This will attest to the fact that you have read the Client Acceptance Policy and understand what is expected of you, as well as what to expect from working with us.

Please review the below: 

1. We will not be ordering any insurance covered services, or filing to your insurance. No ICD-10 codes will be supplied, as we are in no way diagnosing or treating. 
2. If you have not had a physical examination within the last year or since the start of your most recent health problem, it is highly recommended to schedule an appointment with your primary physician within a reasonable time after starting with the coaching process, as your coach will not be doing any physical examination or seeing you in person. Other things such as ultrasounds, scans, or traditional laboratory testing would also be completed outside of this contract with you, we will not order any such testings. 
3. The results of your lab tests may take up to approximately three-to-four weeks. You will be presented with a copy detailing the results of your tests at the scheduled session, not prior to. 
4. Note that any correspondence via text, email, phone, video, Facebook, Instagram, or any other means during and after your entire relationship with us is not HIPAA or medically secure, and you share information on  these platforms willingly.
5. We will do the best to accommodate all scheduling needs. It is your responsibility to reach out and  inquire about setting up a time for your appointment, or scheduling if nothing is available on the online calendar provided. 
6. Payment for this package must be paid in full, or in the agreed upon means. No services will be provided prior to payment.
7. There will be no refunds of payment for services rendered, for any reason, despite the client completing his/her time with us. If refund is requested by the client prior to the service, the client will be responsible for any processing fees involved in the transaction.
8. Once laboratory work is sent out to the client, you are responsible for completing it in a timely manner.  Please let your coach know right away if you will not be able to complete laboratory testing for an  extended period of time for any reason. Initial laboratory work will be included in the cost presented below; follow-up laboratory work will be an additional charge.  Lab work is to be completed in 72 hours of receiving the test, unless otherwise discussed with the coach. Failure to comply with this resulting in testing completed after 30 days from receiving the test forfeits your zoom call with your coach and a report will be sent to you with your results as well as your lab results. 

 

AUTHORIZATION OF CONSULTATIONS: 

I, _____________________________________, hereby authorize health, mindset, lifestyle, and nutritional, and other such recommendations for myself or my minor child by the Company. 

NOTICE AS TO NATURE OF SERVICES: I seek the health coaching services of The Company, employees and staff.  I understand that this team uses some recommendations that some may be considered holistic, complementary or  alternative. Some of these methods have not been accepted by mainstream medicine. I understand that the principles of this practice are based on Functional Medicine, a health system, in which we believe that the body has an inherent ability to heal itself given the right tools. Not all treatment modalities provided by team members are based on science-based evidence. In no way is this team asserting or implying to holding themselves out to be  a Medical Doctor (MD), Nurse Practitioner (NP), or any other medical professional in this consulting relationship.  Furthermore, the term “patient” may be utilized, and is understood as a customary term and does not imply or expressly constitute a conventional doctor/patient relationship has been established. The term “client” will be most solely used. I fully understand that the advice and recommendations that are provided by The Company are  not to be considered medical advice and are for informational and educational purposes only. 

Some of the recommendations and thoughts that are used by The Company include the following: 

1. A person’s lifestyle including his or her diet, exercise patterns, sleep habits and stresses are believed to  be related to the development and maintenance of illness. Your team will evaluate these factors and seek to help the client give up negative lifestyle patterns and establish more positive ones regardless of age or  type of medical problem. 
2. Although prescription and over-the-counter medications are used when a physician believes it is  necessary, an attempt will be made by your team to use products that are naturally familiar to the body. These include but are not limited to, nutritional supplements such as vitamins, minerals, enzymes, amino acids, essential fatty acids and foods. 
3. Because your team will look for imbalances in the body and for trends that may result in illness if not addressed, tests are sometimes ordered that may be considered by consensus mainstream medicine to be either unnecessary or of no value. These may include tests such as those for nutritional status, such as blood or urine levels of vitamins and minerals, hormone levels, the gut microbiome, heavy metals or sensitivities. 
4. Our team feels that environmental factors may play a major role in health and disease. Some of the  diseases of unknown cause may be triggered or perpetuated by common environmental substances, many of which are man-made. Individuals may vary greatly in their susceptibility to various substances, so that one individual may be made deathly ill by an exposure to a substance while another is not at all affected. Your clinicians will attempt to identify offending substances and address past exposures that are affecting them. 
5. Your team very much believes in a person being involved in their own health care and encourages questions, exploration and participation in decisions. 
6. Exercise is extremely important in maintaining health and promoting wellness as well as helping one to  recover from an illness. Graded exercise, both aerobic and stretching, is encouraged for most clients.  We advise that you consult your primary care physician and complete a comprehensive physical exam  before engaging in any such activities. 
7. Sometimes medications are recommended that are approved by the FDA to treat one condition;  however, that same medication may be used for treatment that has not been FDA approved. We will not and cannot prescribe any medications due to the nature of this relationship being that of coaching only. 

NOTICE THAT SERVICES ARE NOT PRIMARY CARE: I understand that no physician or any other practitioner that I see through The Company is acting as my primary care physician or other licensed medical provider. As such, emergency services are not offered. I understand that even though my coaches may address issues affecting my general health, the practice is focused on a complementary, functional, holistic approach to health care and it is required to have a primary care  physician to ensure that I am fully apprised of all available conventional means to address any medical conditions that I may have. This is also important because these practices are exclusively virtual-based and are not affiliated with a hospital. If I become so ill that I require hospitalization, it is vital that I have a primary care physician with hospital admitting privileges familiar with my health problems and history. I understand that in addition to a primary care physician, it may be in my best interest to have appropriate specialists, such as a cardiologist if I have cardiac problems or a pediatrician if I am seeking treatment for my children. 

 

PERSONAL RESPONSIBILITY  & ASSUMPTION OF RISK:  I acknowledge that I take full responsibility for myself and all decisions made before, during and after the Program and I knowingly assume all of the risks of the Program related to my use, misuse, or non-use of the Program or any of the Program content or materials. I agree to: (1) be mindful of my own well-being during the course of this Program, and (2) recognize that I am solely responsible for my results. 

 

NO GUARANTEES: I understand that the company has used care in preparing the information provided to me, but this Program and Program materials are being provided as self-help tools for my own use and for informational and educational purposes only. There are many factors that influence results, so no guarantees can be made as to the results I will experience through this Program. I agree that the company is not responsible for my physical, mental, emotional and spiritual health, or for any other result or outcome that I may experience through this Program. Nothing related to this Program is intended to be considered medical, mental health, legal, financial, or religious advice in any way. For specific questions related to a medical or mental health situation, I must consult my own medical or mental health professional. For specific questions related to my financial, legal or tax situation, I must consult my own attorney, accountant, and/or financial advisor. For specific questions related to religion, spirituality, or faith, I must consult my own clergy member or spiritual healer. I shall not start or stop taking any medications because of anything I have read or received through this Program. Any recommendation of any specific programs, products or actions are simply offered for educational purposes, and I need to check with my own medical professional before using any of these programs, products or taking any actions that may affect my body or my health in any way. 

REVOCATION OF AUTHORIZATIONS: These authorizations will remain active unless revoked by me in writing at  any time. I understand such revocation will not affect my financial responsibility to pay for services rendered. 

NUTRITIONAL SUPPLEMENTS: I understand that The Company and team members will make nutritional  supplements and other recommended products available. Many of these products are not available through retail outlets. These are provided for the convenience of clients, and The Company may receive a small commission for the purchase. I am in no way obligated to purchase these products from my coach. I am free to purchase any recommended supplements or other products from any source that I choose. I further understand that my coaches make no statement expressed or implied about any product recommended that it is intended to diagnose or to treat any disease. No statements made by The Company are evaluated by the FDA. 

INSURANCE CLAIM MANAGEMENT: We do not participate nor are contracted with any insurance company. We  will not provide a receipt and an encounter form to submit to insurance, and do not prepare or submit insurance claim forms. We are not obligated to respond to insurance carrier requests for information, and are not obligated to take action on my behalf against an insurance carrier for collecting or negotiating my any claim. 

I am responsible for the payment of services provided by The Company at the time of service without regard to insurance coverage. I am entitled to know the cost of all services and procedures in advance and it is my  responsibility to ask if they are not told to me. 

 

GOVERNING LAW: This Agreement shall be construed according to the laws of the County of Erie and in the State of New York.

FINANCIAL INSURANCE RESPONSIBILITY FOR ALL SERVICES: I, the client, understand my responsibility to pay includes fees for  laboratory and/or other clinical diagnostic testing and/or services requested by The Company. I also agree to be  responsible for costs and expenses, including court costs, attorney fees and interest, should it be necessary for The  Company to take action to secure payment of an outstanding balance owed. 

Any and all past due client balances, if applicable, will be collected before my appointment. In addition to the fee for consultations, the cost for lab work or other specialized testing deemed appropriate to my case will be applied to my balance if necessary. 

We are committed to providing the best consultations for clients. All appointments are considered confirmed at  the time they are made. I understand all payments must be made prior to appointment time. Because a substantial  amount of time has been set-aside for me, I will forfeit any charges for a missed appointment. If an appointment is missed, I am not guaranteed a make-up appointment for that week, it is my responsibility to re-schedule, and my allotted time with The Company will not be extended, under any circumstances. If I need to miss appointments due to illness, vacation, travel, or family emergencies, I am not guaranteed additional appointments to make up for that time, and will still be responsible for the cost of that appointment. I understand that I need to make my best  attempt to contact my consultant 48 hours in advance if I cannot keep the appointment. 

It is clear that there will be no refunds for any services agreed upon by myself and The Company. If I pay in full and am unable or unwilling to complete my time with this company, regardless of how much time, if any, we have spent together, I do not receive a refund for my payment. If I am on payment plans, I fully agree and understand  that I am responsible to fulfill all monthly payments in one month increments from the first payment, and I will not be given any consultations or email access until that payment is complete. If I am on payment plans, I certify that I will complete  all months of payment regardless of if I complete my work with my consultants, or discontinue services, and regardless if I miss an appointment, or even entire months with my coaches regardless of what the reasoning may  be. In addition, if I miss an appointment, or multiple appointments due to any reason, I will not be granted additional time onto your package. I am fully aware there are no “pauses” in my when I sign on as a client, my time with the Company is for consecutive months, with no exceptions. If I must miss a month or multiple months, I do not get reimbursed for that payment or time. There are no partial refunds. If a payment plan is chosen, I understand I am fully responsible for payment prior to my first appointment.

 

PAYMENT AUTHORIZATION AND RECEIPT:  If paying by debit card or credit card, you give us permission to automatically charge your credit card or debit card as payment for your Program without any additional authorization, and you will receive an electronic receipt.  If I choose to provide you with a Paypal or Stripe invoice instead, you are required to manually pay it by the date due on the invoice or your Program will be put on hold until payment is made. Please note that chargebacks are not permitted and you are agreeing that upon enrollment and by participating in this Program for any length of time, you will make payment in full.

 

MISSED PAYMENT:  If payment is not received by the date due or there is a problem with the payment transaction or method, you will be notified by e-mail or text and then have a 3 day grace period to make the payment following the due date, otherwise your Program will be put on hold. If no payment is made within the 3 day grace period, your access to the Program will automatically terminate and you will no longer be granted access.  

 

COMPANY INTELLECTUAL PROPERTY RIGHTS: I understand that the company retains all ownership and intellectual property rights to the Program content and all materials provided to me through the Program, including all copyrights and any trademarks belonging to the company. The Program content and materials are being provided to me for my individual use only and with a single-user license which means that I am not allowed or authorized to share, copy, sell, post, distribute, reproduce, duplicate, trade, resell, exploit, or otherwise disseminate any portion of the Program or Program materials, electronically or otherwise, for business or commercial use, or in any other way that earns me money, without the company’s prior written permission. 

 

DISPUTE RESOLUTION:  Should we ever have any differences, it is hoped that we could work them out amiably through e-mail correspondence. However, if we are unable to seek resolution in 14 days, we agree now that the only method of legal dispute resolution that will be used is binding arbitration before a single arbitrator, jointly selected by both of us, unless we both agree otherwise in writing. I understand and agree now that the only remedy that can be awarded to you through arbitration is the full refund of my Payment made to date. No other actions or financial awards of consequential damages, or any other type of damages, may be granted to me. We both agree now that the decision of the arbitrator is final and binding and may be entered as a judgment into any court having the appropriate jurisdiction. I also agree that should arbitration take place, it will be held in the County of Spartanburg in the State of South Carolina where the Company’s principal place of business is located, and the prevailing party shall be entitled to all reasonable attorneys’ fees and all costs necessary to enforce the decision of the arbitrator.

 

NON-DISPARAGEMENT:  I agree to not publicly or privately make any negative or critical comments about the Program, the Company or coach(es), or to communicate with any other individual, company or entity in a way that disparages the Program or harms the Company’s reputation in any way, including on social media, at any time. In arbitration or when required by law, of course, I am not prohibited from publicly sharing my thoughts and opinions.

 

FORCE MAJEURE:  In the event that any cause beyond the company’s reasonable control, including, without limitations, “acts of God”/nature, war, curtailment or interruption of transportation facilities, threats or acts of terrorism, State Department travel advisories, labor strikes or civil disturbances, unforeseen or foreseen human-initiated circumstances, health or travel restrictions, quarantines, lockdowns or precautions imposed by any government entity or agency, local, state or federal law or ordinance, or other instances, make it inadvisable, illegal, or impossible for me to perform my responsibilities or obligations under this Agreement, either because of unreasonable increased costs or the risk of injury, the company will not be liable for a reasonable period of delay or for the inability to indefinitely fulfill our responsibilities and obligations.

TESTIMONIALS: By executing this Agreement, Client agrees to permit The Company to use, publish, post and/or communicate any testimonial, whether issued via text message, email, phone call or social media, for marketing purposes including but not limited to social media posts, website or webpage posts, blogs, direct messaging and/or paid advertising, and hereby grants The Company a royalty-free, perpetual, non-exclusive, unrestrictive, worldwide license to use, distribute, post, advertise, communicate, transmit, copy, edit, exploit or otherwise publicly disseminate any communication or testimonial submitted by Client, in whole or in part, with or without identifying Client as the author of the original communication nor testimonial. If The Company so chooses to identify Client, Client also grants The Company the right to identify Client as the author of any such communication or testimonial, by name, initials, email address, screen name, or any other reasonable manner of identification.

 

CLIENT ACKNOWLEDGEMENT: I certify that I am here to receive coaching services only and/or they are not substitution for appropriate medical care. I do not represent any third party. I have read, understood and agree to the foregoing. I understand that I have the right to review this consent with an attorney if I choose before accepting any consultation or services. I have executed this consent freely and willingly understand its provisions. I recognize that The Company will rely upon my signing of this document in accepting me as a client and establishing  me under legal contract. I acknowledge receipt of a copy of this consent if I have requested it. 

I do hereby acknowledge that by signing this statement of understanding that I understand that some, and perhaps all, of the coaching, preventative, nutritional, and lab data recommendations provided may be innovative, non-traditional or unconventional and is coaching only and not to be construed to qualify as medical or nutritional advice and it is for informational and educational purposes only. I also understand that these unconventional services may be viewed by 3rd party insurance purveyors as non-covered services, in that they might be considered unreasonable or unnecessary under any medical insurance program. I also realize that my insurance coverage does not pay for such services and that I will be personally responsible for payment. I understand that I will pay all costs including reasonable attorney fees, should that become necessary. I understand  that all outstanding balances bear interest at the maximum rate allowed by law. 

TERMS AND SERVICES: This agreement is for the ‘Wellness Lab Package’ which includes a GI Map test kit x1, ZRT Weight Management Hormone Panel x 1,  a 60 minute private zoom session x1, Recording of zoom call, a custom action plan provided via PDF. There will be no emailing for advice outside of the zoom session. 

If paying in full, client agrees to pay The Company a total amount of two-thousand ($2,997) USD via Kajabi payments which is due upon enrollment and prior to lab ordering. 

If opting for the payment plan, this is 2 consecutive monthly payments of one-thousand-seven-hundred forty-nine dollars ($1,749) USD; first payment is due immediately upon enrollment and the 2nd will be due 1 month later and before your lab review session takes place. 

Company: Sarah Mathis Wellness LLC 

E-mail: [email protected]

Date: 6/11/24