Client Service Agreement:
This form is a legal document that explains the risks the client assumes when partaking in services and/or a wellness program with Amie Hornaman Nutrition and Functional Medicine. It is important that the client read and understand it completely. The client gives consent to Amie Hornaman to provide nutrition and health consulting to him/herself or the individual for which he/she is legally responsible.
The nutrition and health advice given is solely based on the information provided by the client. It is the client’s responsibility to provide complete and accurate information. Any misinformation, inaccurate or omitted information may affect the assessment and/or recommendations given. Any misrepresented information is the client’s responsibility entirely and Amie Hornaman will not be liable. All personal information the client shares with Amie Hornaman will be kept strictly confidential.
By signing below, you agree to the following:
“I, the client, understand that I am entering into an agreement with Amie Hornaman Nutrition and Functional Medicine for the service of nutrition and functional medicine consulting. I understand that I must trust the process, ask questions and check in on a regular basis with Amie Hornaman. I understand that I am not entitled to a refund of any monies should I decide I am not satisfied with the program, I am to reach out to Amie Hornaman to communicate any issues or concerns I have with the program. I am responsible for fulfilling my monthly obligation and for reaching out for accountability and support.
I understand that I will be automatically billed XX each month until cancelled or until my designated program is complete. The monthly charge includes a 45-60 min progress evaluation and continuation of the program along with nutrition and health plan changes as well as 24/7 access to Amie Hornaman for support and accountability. I am responsible for making and keeping my monthly appointments.
I am acting solely on my own behalf. I do not represent any other person, entity, and/or governmental agency.
I understand a 48-hour cancellation is requested to avoid being charged a cancellation fee of 50% of the cost of the session within 24-48 hours and 100% charge within the 24-hour time frame. Cancellations may be provided via phone or email and it is my responsibility to reschedule any missed appointments due to my cancellation.
I understand services are not a substitute for medical care, and Amie Hornaman Nutrition and Functional Medicine does not claim to diagnose, treat, or alleviate disease. Additionally, I understand I will need to consult with a medical physician for the medical diagnosis and treatment of disease. “
There is a $35.00 charge on any returned or NSF checks.
All information given to you in the form of emails or handouts are the intellectual property of Amie Hornaman. They are not to be used in any other way other than for personal health purposes.
By filling out the form below, I acknowledge that I have read the above text in its entirety, and I agree to its terms: