New Patient form Paperwork - Living Well Clinical Nutrition

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Fees and Policies This is our current fee structure as of 03-July-2025. Our fees are subject to change at any point. We will confirm fees with you at time of scheduling.

At your appointment: We appreciate the fact that people have schedules to follow and for that we do our very best to run on time. This ensures that you know when your appointment begins and ends and can make plans accordingly. This also ensures that you get the full allotted time for your visit. We do ask that arrive 15 minutes early for your appointed time.

Payment: Payment is due at the time of services rendered. We accept cash, check, and credit cards. We do not accept insurance. Payment for an “Initial Evaluation” is required at the time of scheduling.

Cancellation Policy: If for some reason you must reschedule or cancel your existing patient appointment, we do ask that you give us 24 hours notice. If we do not answer the phone, please leave a message because the machine will identify the date and time that you called. By giving us 24 hours notice, it allows us to fill the spot with another patient on our waiting list. If we do not receive 24 hours notice, we will charge you in the amount of the appointment that you missed, and that must be collected before rescheduling your next appointment.

Note: Our “Initial Evaluation” reschedule/cancellation policy is at least 7 days notice prior to the scheduled appointment date for a full refund. If we do not receive 7 days notice there will be a $60 cancellation fee applied and the remainder of your “Initial Evaluation” payment will be refunded.

Office Fees: Our fees are based on the time that you spend in the office. If the patient does not complete a nutrition or a chiropractic appointment with Living Well within 1 year, the patient will be required to complete a reevaluation appointment

Initial Nutrition	$220.00
Initial Chiropractic Evaluation	$120.00 - $220.00
Initial Nutrition and Chiropractic Evaluation	$300.00
Initial Nutrition Evaluation for infants under 12 months (includes chiropractic)	$140.00

ACTIVE PATIENT: An active patient is a patient that has completed a nutrition, chiropractic or
specialty appointment within the last 12 months. In order to qualify for a “In Office Discount” on
supplements, the patient will need to have been seen in the last 90 days.

Additional Fees: Supplements and laboratory work are NOT included in the price of the visit. This amount will vary based on your evaluation. Blood work is discounted over 75% as a client of Living Well Clinical Nutrition Center.

Supplement Return Policy: Supplements must be returned within 30 days of purchase, in original packaging/unopened/ unexpired, and have the original receipt as proof of purchase.
Fees and policies are subject to change without notice.

Client CONSENT

HEALTH AND WELLNESS
We want you to be informed about our goals, philosophies, and expectations at Living Well Clinical Nutrition Center in regards to how we work to achieve health and wellness for you and your family. It is our premise that nutrition, energy, and a properly functioning nervous system are the building blocks of life. When these foundational aspects are balanced, it allows the body the opportunity to optimize its own naturally occurring recuperative abilities. With this in mind, we seek to restore health through natural means without the use of drugs or surgery. (If medication or surgery is warranted, we advise the individual with the building blocks of life, we give their body the maximum opportunity to utilize its inherent recuperative powers.) We do not claim to treat or cure any specific disease or condition. The staff at Living Well Clinical Nutrition Center provide a specialized, unique, non-duplicating health service and are certified in their special areas of practice.

ANALYSIS AND APPROACH
At your appointment, we will conduct an analysis for the express purpose of determining the nutritional, neurologic, and/or energetic deficiencies or any interference that hinders you from achieving optimal wellness. Specialties of our practitioners include Applied Clinical Nutrition, Applied Kinesiology, Quantum Neurology, joint mobilization, Neuro-Emotional Technique, diet and weight loss support, detoxification, cold-laser therapy, family and pediatric wellness. They will utilize the aforementioned, safe and non-invasive techniques to achieve your optimal wellness

RESULTS
The purpose of office visits is to promote natural health through the stabilization of the nutritional, neurological, and energetic systems of your body. Due to the individuality of every person, it is difficult to predict the healing time. Most often the response is incredible as to how the body begins to heal quickly, however, in some cases, there is a more gradual healing process. Two or more similar conditions may respond differently to the same type of care and actual response time is unpredictable. Many conditions, for which the medical field has not found much improvement, have found significant benefit through the approach we use at Living Well Clinical Nutrition Center. Our practitioners work with you to help you make an informed decision prior to being accepted as a new client.

DIAGNOSIS
Although the staff at Living Well Clinical Nutrition Center are experts in the analysis of the nutritional, neurological, and energetic aspects of the human body, they will not make a diagnosis outside of their scope of practice. Individuals that require additional testing (MRI, X-Ray, Blood, etc...) will be informed of and have access to those reports at any time.

INFORMED CONSENT
By signing this page, you give Living Well Clinical Nutrition Center permission and authority to use any or all of the aforementioned analyses and techniques. You are giving permission to utilize the gathered data, according to HIPAA guidelines (no use of names/complete anonymity, etc...), for research, research presentations, and other office applications should the practitioners deem the case appropriate. It is the responsibility of the client to make any diagnosed or observed deformities, injuries, illnesses, or other pathological conditions known in order to receive the most optimal care. If you have any further questions concerning our office, please feel free to ask.

ADDITIONAL CONSENT
By signing, you also understand our fee policy, scheduling policy and return policies.
To the best of your knowledge, everything you are submitting in this new patient packet is true.

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