Please read the following prior to booking this appointment with us.
EARTH NATUROPATHIC IS A SCENT FREE FACILITY. PLEASE REFRAIN FROM USING PERFUMES AND COLOGNES. THANK YOU FOR YOUR COOPERATION.
Hello, welcome to the office of Earth Naturopathic, the office of Dr. Terra Winston! I look forward to helping you reach your health goals with naturopathic medicine. I encourage your questions and participation in all aspects of your wellness journey. This document explains our policies and practices and collects your informed consent to receive treatment from Earth Naturopathic.
Please make sure to read through this document in its entirety, and check the box above once you have read the policies.
1. OFFICE POLICIES
We have developed the following policies to ensure we provide the best care possible to each patient. * We cannot act as your primary doctor and require you to have a primary care physician on record.
* We are not an urgent care facility and do not provide emergency services. If you have an urgent issue, dial 911 or go to your closest emergency room/urgent care facility.
* We are a self-pay practice. We accept cash and credit cards for payment. We do not submit claims to Medicare, Medicaid, or private health insurance carriers.
* Fees are charged according to our Fee Schedule is available upon request.
*A deposit of 250.00 is due at the time scheduling to hold your "IV" appointment. The deposit will cover the cost of the first visit and will be deducted from the balance of the program cost if you decide to move forward.
*Cancellations of "IV” appointments prior to one week of scheduled appointment will be refunded at $250.00. Cancellations of "New Patient" appointments within one week of appointment will be refunded at $150.00 *Any remaining payment is due at the time of service.
2. APPOINTMENT AND CANCELLATION POLICY
To provide you with high quality care, we reserve a special appointment time just for you. A missed appointment or late cancellation results in lost time that could have been given to another person wanting to receive care. We have adopted the following policies to facilitate patient appointments and care:
*It is the patient’s responsibility to keep record of appointments and to arrive on time. We may send you appointment reminders as a courtesy but please do not rely on this as your sole form of remembrance.
*Patients arriving more than 15 minutes late to their appointment will be subject to the provider's discretion as to whether they can be seen. Late arrivals may also be subject to an abbreviated visit. *If the provider determines that a patient cannot be seen, or if the patient is more than 20 minutes late for a scheduled appointment, it will automatically be considered a no-show and the patient will incur a $175 missed appointment fee.
*Please call at least 48 hours in advance if you need to cancel or reschedule your appointment. The 48-hour advance cancellation does not include weekends. Earth Naturopathic reserves the right to modify or refuse appointments for patients who habitually late cancel or no-show appointments.
*We realize that an emergency may occur and/or you may not be able to notify us at least 48 hours in advance. In that case, please inform us of the situation and we will discuss the appropriate outcome.I have read and I agree to the Appointment and Cancellation Policy.
3. INSURANCE AND PAYMENT POLICY
Earth Naturopathic is not currently contracted with any insurance companies and does not offer billing services. Fees are charged based on our Fee Schedule, which is available upon request. Payment in full is due at the time of service. For your convenience we accept cash or credit card. If you are dissatisfied with your service, or the supplements you purchased, please let us know and we will do our best to make it right. Many private insurance companies have policies that do cover some or part of the care you will receive from us. Your insurance may also be used to cover the cost of labs and imaging, and prescription drugs when applicable. Your health insurance policy is a contract between you and your insurance company, and you are responsible for knowing your coverages. If you are unsure of your coverage limits, please contact your insurance provider and request an EOB. If you currently have Medicare, Medicaid, or Tricare please inquire about Dr. Terra's non-profit billing options.I have read and agree to the Insurance and Payment Policy.
4. EMAIL POLICY
Established Patients are welcome to contact us via the email between appointments to clarify treatment plan instructions. However, messages are not a substitute for an office visit. If your doctor determines that your email is complex, requires professional advice, or will result in an alteration to your treatment plan, we will contact you to establish care if you have not already, which is a new patient visit, or if you are established, schedule a 15-30 minute in-person or phone or Zoom consultation. These consultations are billable at our regular office rates according to our Fee Schedule, with payment due via credit card at the end of the consultation.I have read and agree to the Email Policy.
5. INFORMED CONSENT
This Informed Consent provides you (or your authorized representative) the opportunity to become better informed so that you may give or withhold consent to undergo diagnosis and treatment after having an opportunity to discuss health concerns. I hereby authorize Dr. Terra Winston, in accordance and within the scope and limits of her clinical license, to perform or recommend any of the following procedures for diagnosis and/or treatment:
*Treatments: Venipuncture, radiography, laboratory, x- ray, ultrasound, and devices that may fall outside of the “conventional standard of care.”
*Lifestyle Counseling: therapeutic dietary advice and guidelines and the promotion of wellness including, but not limited to, recommendations for sleep, exercise, stress management and reduction, balancing of work and self-care activities, and developing and nurturing healthy relationships and community relationships.
*Medical Nutrition: therapeutic nutrition, nutritional supplementation, intravenous and intramuscular vitamins, minerals, amino acids, lipids, and phytonutrients as permitted by licensure.
*Botanical Medicine: medicinal herbs and plant derivatives prescribed as loose teas, alcohol or glycerin tinctures, capsules, tablets, creams, suppositories, etc.
I understand that treatment may result in the restoration of health and optimal functional capacity, relief of pain and symptoms, injury and disease recovery, and prevention or reversal of disease or disease progression, but ALSO acknowledges that no expressed or implied guarantees or representations can or have been made by the clinician or any affiliated staff regarding the cure or improvement of the client’s condition.
I acknowledge and accept that there are risks to the diagnosis and treatment measures that fall within and outside the conventional standard of care, and that these risks may include: unintended exacerbation of symptoms, new symptoms, allergic and other unintended injury, and side effects from exercise, lifestyle modifications, dietary modifications, herbal and nutritional supplements, injected or intravenous therapies, adverse interactions with drugs, herbs and/or nutrients. The specific risks associated with the proposed procedures will been explained to the client and/or the client’s representative as they apply.
I acknowledge that the clinician cannot know or anticipate and explain every possible risk or complication, and that the client or representative willingly chooses to rely on the clinician to exercise their best judgment within the bounds of their licensure for any of the above.
If the patient is female, the patient agrees to alert the clinician should she suspect that she is or may be pregnant in acknowledgement that some of the diagnostic or therapeutic techniques could present risks to a pregnancy.
I understand that I (or my representative) bear full responsibility for any adverse effects experienced during or after the course of treatment that were reasonably deemed to be caused or related to a deficit in the full, accurate and timely disclosure of symptoms and other medical information to the clinician to the best of my or my representative’s ability.
I understand that I am free to discontinue participation in any and all aspects of the medical care provided by the clinician at any time, and that I or my representative is responsible for informing the clinician of the adherence to or discontinuation of any and all aspects of care and that the choice to discontinue treatments may create the risk of adverse effects for which I or my representative bears full and sole responsibility.
I understand that the clinician may consult with preceptors, clinical student residents and colleagues related to the care provided, and that I or my authorized representative have the right to decline their presence or involvement during any aspect of my care.
I have had the opportunity to read and inquire about this consent and all the items addressed herein. I acknowledge the right, opportunity, and responsibility to ask questions and to become informed regarding the clinician’s diagnostic and treatment recommendations to their satisfaction. Client acknowledges that all questions asked have been fully answered by the clinician. I acknowledge and agree that consent form will cover the entire course of treatment for the present condition and for any future condition(s) for which treatment is sought.
By submitting this form I acknowledge that I have been provided ample opportunity to read this document or that it has been read to me. I understand the above-stated office policies and the financial agreement with Earth Naturopathic and will comply with them in all respects. I acknowledge that I have received the Notice of Privacy Practices & HIPAA Compliance Statement.
Lastly, I understand all of the above and give my oral and written consent to the evaluation and treatment to cover the entire course of treatments for my present condition and any future conditions for which I seek treatment.