Atlantic Naturopathic Consent Form

Informed Consent for Naturopathic Care

By signing below, you acknowledge and understand that:

1) Michelle Naman, N.D. and Olivia Froehlich, N.D. have doctorates in naturopathic medicine (collectively, the “Providers”). They are trained in naturopathic medicine, a distinct healthcare practice. They are not medical doctors licensed by the Board of Medical Examiners. They do not diagnose or treat medical conditions in the state of New Jersey, nor do they manage pharmaceutical drugs. Michelle Naman, N.D. maintains a naturopathic physician license in Connecticut, and Olivia Froehlich, N.D. maintains a naturopathic physician license in Vermont.

2) The Providers and their staff at Atlantic Naturopathic, LLC ("we", "us", "our") do not recommend that you discontinue any other treatment or care provided by any other healthcare professional.

3) There is no expressed or implied guarantee of any specific outcome from recommendations provided by the Providers or their staff.

4) Potential risks of naturopathic care include pain, discomfort, allergic reaction to recommended herbs and supplements, or aggravation of pre-existing symptoms. If you experience life-threatening adverse reactions, seek emergency care immediately. It is your responsibility to inform your provider of any adverse reactions, regardless of severity.

5) It is your responsibility to notify your Provider of any changes in your medical history, medications (prescription, over- the-counter, etc.), supplements (herbs, vitamins, minerals, etc.), and risk for potential pregnancy.

6) If you have a true medical emergency or serious medical concern, you are to call 9-1-1 immediately. Atlantic Naturopathic, LLC does not see clients with urgent or emergent conditions.

7) The Providers are not recognized healthcare providers with any insurance companies in New Jersey nor do they submit claims to insurance companies on your behalf. Presently, no insurance companies in the state of New Jersey offer coverage for naturopathic care. The Providers and the staff at Atlantic Naturopathic, LLC do not provide itemized bills or any other documentation to be submitted to insurance. All labs coordinated through Atlantic Naturopathic, LLC are not covered by any insurance.

8) The Providers are not licensed healthcare providers in the state of New Jersey. As such, they are not bound by HIPAA in the state of New Jersey.

9) In preparation for your first visit, you must complete the Atlantic Naturopathic, LLC Intake form at least 2 business days before your visit. We also require that you upload any pertinent labs or imaging records that you'd like to share with your Provider 2 business days before your visit. If these are not completed in time, your Provider reserves the right to reschedule the appointment for a later date.

By signing below, I acknowledge that I have read the above and consent to naturopathic care at Atlantic Naturopathic, LLC.

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Charm Client Portal

Consent to Contact

As a client of Atlantic Naturopathic, LLC, you are required to establish a Charm Client Portal which forwards pertinent notifications to your chosen email address. Therefore, we require every client to provide a valid email address upon scheduling a first appointment.

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Phone

As a client of Atlantic Naturopathic, LLC, we require a phone number at which we can reach you. Your phone number must be provided upon scheduling your appointment as well as entered above in this consent form. It is your responsibility to notify your Provider of a change in phone number.

By signing below, I agree to Atlantic Naturopathic, LLC's "Consent to Contact" policy.

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Email Marketing Policy

1. Purpose of Communications: The purpose of these emails is to provide you with valuable information about our services, promotions, events, and relevant health-related content.

2. Use of Personal Health Information (PHI): We may use your first name to personalize the content of our emails.

3. Right to Withdraw Consent: I understand that I have the right to withdraw my consent at any time by following the unsubscribe instructions provided in each email.

4. Email Content: You have the option to customize your email preferences by choosing to sign up for either the "essentials" or "promotional" email list, neither, or both below.

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By subscribing to our “essentials” email list, you will receive content such as:

- Clinic updates (closures, new providers, etc.)
- Service and offerings updates (price changes, visit types, etc.)
You can expect to receive these emails approximately 0-2 times per month.

I am signing up for the "essentials" email list. *

Yes No

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By subscribing to our “promotional” email list, you will receive content such as:

- Health tips and information
- Promotional offers and discounts - New blog post alerts

- Invitations to webinars, in-person talks and workshops
You can expect to receive these emails approximately 1-2 times per week.

I am signing up for the "promotional" email list. *

Yes No

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7. Double Opt-In Consent: To ensure your consent is explicit, we use a double opt-in process. You will receive a confirmation email once you are added to your selected email list(s). Please click the link in that email to confirm your subscription.

By signing below and clicking 'Submit', I acknowledge that I have read and understood the above terms and agree to receive essential and/or promotional emails from Atlantic Naturopathic, LLC. I acknowledge I have been informed about the purpose of these communications, the type of information that will be shared, and how my PHI will be used as described above.

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Client Fees, Payment & Cancellation Policies Payment Method Policy

We currently only accept payments by credit and debit card bearing a Visa, MasterCard, American Express, Discover, JCB, or UnionPay logo. We require a card on file through Square for all clients and members. You may call at any time to change your current card on file.

Completing this form is an agreement to having your card saved on file which won't occur until the time of your first visit. Please have the below payment information on hand at the time of your visit.

Square Policy

Square requires all customers to complete a credit card authorization form to store their card on file. You may cancel this authorization at any time by contacting us. To remain a client/member at Atlantic Naturopathic, LLC we will require a replacement card on file. This authorization will remain in effect until canceled. Please complete all fields.

Only one card on file may be saved to your account at any given time.

Card Type: *

Cardholder Name (as shown on card): *

Last 4 digits of Card Number: *

Expiration Date (mm/yy): *

Cardholder ZIP Code (from credit card billing address): *

MasterCard VISA AMEX JCB

Discover UnionPay

I, (type name here) *
authorize Atlantic Naturopathic, LLC to charge my credit card above for agreed upon purchases. I understand that my information will be saved to file for future transactions on my account.

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Refund Policy

All consultation, membership, cancellation, and no-show fees are non-refundable. Any and all supplements that are bought in-office are non-refundable.

Supplements purchased through Fullscript are not refundable by Atlantic Naturopathic, LLC, but may be refundable through Fullscript.

Any personalized formulas such as tinctures or supplement powders/capsules are non-refundable. All labs that are coordinated through Atlantic Naturopathic, LLC are non-refundable.

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Fee Policy for Non-Members & Members

The following fee schedule is in regard to the services that Atlantic Naturopathic, LLC and its Providers render to their clients. These fees do not include any additional costs such as labs, products purchased, or any other services pursued after meeting with either of the Providers.

Are you signing up for or currently on membership? *

Yes No

If you answered "yes" above, are you joining a current member's family plan as a 2nd, 3rd, 4th, etc. addition? * Yes No

If you answered "yes" to signing up for or currently on membership please proceed to the "Membership Pricing" heading.

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Non-Membership Pricing (Priced Per Visit)

1. New Client Visit (90 minutes): $350.00
This visit is for all new clients--those who have never been seen at Atlantic Naturopathic, LLC and those who haven’t been seen by their provider at Atlantic Naturopathic, LLC for more than 3 years. This visit is prefaced by completing thorough intake paperwork, reviewing and signing our consent forms, and preparing and sending any relevant lab work, imaging, or diagnosis information to your provider. This is a 90-minute visit.

2. New Client Visit, Internal Referral (90 minutes): $300.00
This visit is for clients established with a provider at Atlantic Naturopathic, LLC who have been seen within the last 3 years and have been referred to another provider within Atlantic Naturopathic, LLC who has not seen them before. This is a 90-minute visit.

3. Return Client Follow-up Visit (50 minutes): $250.00
This visit is for clients established with a provider at Atlantic Naturopathic, LLC who have been seen within the last 3 years and are returning to that same provider. This is a 50-minute visit.

4. Return Client Follow-up Visit Extended (65 minutes): $295.00
This is a 50-minute visit with a 15-minute extension should the provider and client agree and the provider's schedule allows. This visit is for clients established with a provider at Atlantic Naturopathic, LLC who have been seen within the last 3 years and are returning to that same provider.

5. Return Client Check-in Visit (30 minutes): $175.00
This visit is for clients established with a provider at Atlantic Naturopathic, LLC who have been seen within the last 3 years and are returning to that same provider. This is a 30-minute visit. Requests to schedule will be reviewed by your provider before confirmation. If the nature of the visit seems more complex than time will allow, a “Return Client Follow- up Visit” will be proposed instead.

6. Acute Visit (30 minutes): $125
This visit is for new or established clients and is telehealth only for non-emergent conditions such as colds, flu & other acute illnesses. Must call to book.

7. Phone/email contact. All contact made regarding clarification, questions, or concerns about recommendations from your provider at Atlantic Naturopathic, LLC is free of charge. However, if your provider deems that a message is too complex to answer via message, a visit may be suggested.

Non-Membership Visit Cancellation Policy​

How to cancel your appointment:

Appropriate methods to cancel or reschedule an appointment include the following: call our clinic at (732) 704-4877 or message your provider through Charm. If your call is not answered, please leave a voicemail. Your call, message, or voicemail alone suffices as a notification for canceling your visit.

A business day is defined as any day except Saturday, Sunday, and any federally recognized holiday.

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Cancellations:

No cancellation fee is applied if you cancel with appropriate notification one business day or more BEFORE your scheduled visit. This means a Monday appointment should be canceled by the appointment time on the Friday of the previous week. Appropriate notification is defined under "How to cancel your appointment" above.

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Late cancellations:

Clients who cancel with appropriate notification within one business day of their scheduled appointment will be subject to a “Late Cancellation” fee of 50% of their scheduled visit fee. A business day is defined as any day except Saturday, Sunday, and any federally recognized holiday. Appropriate notification is defined under "How to cancel your appointment" above.

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Late shows:

We understand that delays are a part of life, however, we must also prioritize our Providers’ and their other clients’ time by staying on schedule. In any event of a client arriving late to their visit, the appointment will not be extended, rather it will end at its scheduled time. If a client is 15 minutes late to their NEW or RETURN client visit, the visit will automatically be canceled and the client will have to reschedule. If a client is 5 minutes late to their 30-minute CHECK- IN visit, the visit will automatically be canceled and the client will have to reschedule.

If a client is late to the extent of the visit needing to be rescheduled, this will count as a “Late Cancellation”. The first time a visit needs to be rescheduled due to tardiness, the client will not be charged a “Late Cancellation” fee. Any additional occurrences will result in the client incurring a “Late Cancellation” fee as detailed above.

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No-shows:

Clients who fail to show for their scheduled appointment without appropriate notification before the start of the visit will be subject to a “No-Show” fee of 80% of their scheduled visit fee. Appropriate notification is defined under "How to cancel your appointment" above.

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Payment policy regarding No-Show/Late Cancellation fees:

The appropriate fee will be charged to your card on file within one business day of the missed or canceled appointment.

In the event of an actual emergency that prevents a client from keeping their scheduled appointment, consideration will be given, and a one-time exception may be granted.

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Membership Pricing

A membership with Atlantic Naturopathic, LLC includes an initial client visit, unlimited 15-, 30- and 50-minute visits, reduced cancellation fees, and no membership cancellation fee.

1. The membership fee is $200/month. This will be charged to the card on file starting on the day of the client's initial visit with their provider. The membership fee will recur as automatic payments to the card on file every month through Square. If your recurring invoice is set to recur on the 29th, 30th, or 31st of the month, it will instead be sent on the last day of the month. This ensures an invoice is sent or charged even in months having fewer days. This is a policy created by Square, and not controllable by Atlantic Naturopathic, LLC. If you have an end-of-month invoice and instead prefer it to recur on the 28th, please let your provider know.

2. There is a one-time registration fee of $350. This will be charged to the card on file the day of the client's initial visit with their provider. This fee will be waived if a new client, who originally paid for their initial visit with their provider outside of the membership model, decides to upgrade to the membership within 30 days of their initial visit or by their next visit if it occurs before 30 days.

3. If the decision to begin membership occurs within one month of the first visit, the first month's membership fee will be charged to your card on file. Your recurring membership fee will be charged every month following this initial monthly payment.

If you pay for your full year upfront, you will get one month free, totaling $2,550 ($350 + 11x$200). This will be a one time charge at the time of the client's initial visit, and will renew yearly at $2,200 (11x$200).

4. Memberships must be canceled 20 days before your next invoice is set to occur. There is never a fee to cancel your membership. If you cancel your membership, you will default to the non-membership pricing/cancellation policy (please review above).

5. If a client cancels their membership and wishes to resubscribe at any time, they will incur the one-time registration fee of $350 upon resubscribing.

6. To manage your membership, including canceling, freezing, or prepaying, please go to https://www.atlanticnaturopathic.com/membershipmanagement, click "Manage my Membership" and complete the form.

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Family Membership Criteria and Pricing

All features of membership apply to each family member. Family members must be a part of the same household.

Each family member establishes with the same core provider. Acute visits may be booked with another provider if necessary.

The first family member pays standard membership registration and monthly fees detailed above under "Membership Pricing". Each subsequent family member added will receive an additional $50 off their registration fee and $25 off their recurring monthly membership fee.

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Membership Visit Cancellation Policy

How to cancel your appointment:

Appropriate methods to cancel or reschedule an appointment include the following: call our clinic at (732) 704-4877 or message your provider through Charm. If your call is not answered, please leave a voicemail. Your call, message, or voicemail alone suffices as a notification for canceling your visit.

A business day is defined as any day except Saturday, Sunday, and any federally recognized holiday.

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Cancellations:

No cancellation fee is applied if you cancel with appropriate notification one business day or more BEFORE your scheduled visit. This means a Monday appointment should be canceled by the appointment time on the Friday of the previous week. Appropriate notification is defined under "How to cancel your appointment" above.

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No-Shows and late cancellations (within one business day):

As a member, there is a flat $50 no-show/late cancellation fee. A no-show is defined as a client that does not show up for their scheduled visit without appropriate notification before the start of their visit. A late cancellation is defined as canceling an appointment within one business day of the scheduled visit. A business day is defined as any day except Saturday, Sunday, and any federally recognized holiday. Appropriate notification is defined under "How to cancel your appointment" above.

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Late shows:

We understand that delays are a part of life, however, we must also prioritize our providers’ and their other clients’ time by staying on schedule. In any event of a client arriving late to their visit, the appointment will not be extended, rather it will end at its scheduled time. If a client is 15 minutes late to their NEW or RETURN client visit, the visit will automatically be canceled and the client will have to reschedule. If a client is 5 minutes late to their 30-minute CHECK- IN visit, the visit will automatically be canceled and the client will have to reschedule.

If a member is late to the extent of the visit needing to be rescheduled, this will count as a “Late Cancellation”. The first time a visit needs to be rescheduled due to tardiness, the member will not be charged a “Late Cancellation” fee. Any additional occurrences will result in the member incurring a “Late Cancellation” flat $50 fee.

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Payment policy regarding No-Show/Late Cancellation fees:

The flat $50 fee will be charged to your card on file within one business day of the missed or late-canceled appointment.

In the event of an actual emergency that prevents a client from keeping their scheduled appointment, consideration will be given, and a one-time exception may be granted.

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Client Fees, Payment & Cancellation Policies Acknowledgement

I agree to make payment according to the policies of Atlantic Naturopathic, LLC. If not signing up for membership service, I understand that payment is due in full at the time of service. If signing up for membership service, I understand that the registration fee and first month of membership are due at the time of my first visit, and the monthly membership fee is recurring and charged to my card on file.

I understand the cancellation policies and that if I incur a fee, it will be charged to my card on file. We reserve the right to make changes in our fees and/or policies without advance notice.

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Individualized Tincture Agreement

One of the services our Providers may provide at Atlantic Naturopathic, LLC is formulating individualized tinctures.

Your provider will inform you of the amount of tincture to be created and the corresponding price, and ask for verbal or written (i.e. Charm message) consent. Following consent, your card on file will be charged and your provider will formulate your individualized tincture. Your individualized tincture will take a minimum of 10 days before it is completed. Individualized tinctures will need to be picked up in office unless previously discussed with your provider.

Signing this consent form indicates your understanding that once you and your provider decide an individualized tincture is right for your care, you are bound to pay for the tincture at that time.

Tincture prices are as follows: 2 oz – $28
4 oz – $56
8 oz – $96

16 oz – $192
Prices are subject to change without advance notice. Individualized tinctures cannot be returned or refunded. I understand and agree to the above terms and conditions.

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Personalized Nutrients Agreement

Another service our providers offer is custom formulated powders or capsulated supplements through a company called Personalized Nutrients.

Your provider will inform you of the proposed formula form (powder/capsule) and cost, then ask for verbal or written (i.e. Charm message) consent to order the formula. Following consent, your card on file will be charged and your provider will submit the order. The lab’s formulating, processing, and shipping usually takes 12-16 days from when your provider submits the order. It will be shipped to your address on file.

Personalized Nutrients products cannot be returned or refunded. I understand and agree to the above terms and conditions. 

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Consent & No Duress or Coercion Acknowledgement

I agree and acknowledge that I am under no pressure or duress to sign this Agreement, nor was I coerced to do so, and that I have been given a reasonable opportunity to review it before signing.

I am at least 18 years or older. I have read this document completely and I understand and agree to all of its contents demonstrated by my signature below.