INTEGRATIVE HEALTH SERVICES AGREEMENT
INFORMED CONSENT, TELEHEALTH CONSENT, FUNCTIONAL LAB TESTING WAIVER
Practitioner Name: Sydney Ryan
Sydney Ryan Integrative Health LLC
Congratulations, you are taking a great step towards better health & wellness
It is common practice for integrative health practitioners and other non-licensed practitioners to collect your signature on a liability waiver form such as this. By doing so you acknowledge that it is your responsibility to deliver all laboratory test results, now and in the future, to your own physician for any medical interpretation or opinion regarding any laboratory results provided by Sydney Ryan or her affiliates. The undersigned agrees that he or she will receive a nutritional interpretation of the test results from Sydney Ryan that is to be used exclusively by the undersigned as an educational tool for personal health purposes. However, the personal physician of the undersigned may use these same laboratory results to diagnose and treat disease. The undersigned releases Sydney Ryan from any liability for injury or loss arising out of the use of, or reliance on, the laboratory results and/or the dietary, supplement and lifestyle suggestions provided. Before making any changes to the exercise, diet or nutritional or hormonal supplementation of the undersigned, a physician should be consulted.
Sydney Ryan does not diagnose, cure or treat any illness or disease. Any labs that are done are for educational purposes only. This information is not intended to, cannot, and should not be expected to substitute for a personal consultation with your own physician. Further, the undersigned releases Sydney Ryan and her lab partners, from any and all liability for any failure to identify any medical condition or disease. It is understood and agreed that this is not the purpose of their services.
1. PURPOSE OF SERVICES
The services provided through this practice are intended to support general wellness, lifestyle improvement, and health education through integrative health approaches. Services may include wellness consultations, lifestyle and nutrition guidance, educational interpretation of functional laboratory testing, and recommendations intended to support overall health.
These services are not intended to diagnose, treat, cure, or prevent any disease.
2. NOT MEDICAL CARE
The client understands that the practitioner is not acting as the client’s primary medical provider. The services provided are not a substitute for medical care, diagnosis, or treatment provided by a licensed physician or other qualified healthcare professional.
Clients are encouraged to maintain a relationship with a licensed primary healthcare provider and to consult them regarding any medical condition, medication changes, or treatment decisions.
The practitioner does not prescribe medications, diagnose medical conditions, or provide emergency care.
3. CLIENT RESPONSIBILITY
The client acknowledges that they are responsible for their own health decisions. Any wellness recommendations provided are intended for educational purposes and should not be interpreted as medical advice.
The client agrees to consult their licensed healthcare provider before making changes related to medications, medical treatments, or the management of diagnosed conditions.
4. FUNCTIONAL LABORATORY TESTING CONSENT
Clients may elect to obtain functional laboratory testing through third-party laboratories. These tests may include blood, urine, saliva, stool, or other biological samples depending on the test selected.
The client understands and acknowledges that:
• Laboratory testing is voluntary.
• Testing services are provided by independent third-party laboratories.
• The practitioner does not control laboratory operations, processing procedures, or laboratory accuracy.
• Laboratory results may not provide definitive medical diagnoses.
• Interpretation of results provided by the practitioner is educational focused.
The client understands that laboratory results should be reviewed with their licensed healthcare provider if medical diagnosis or treatment is needed.
5. RISKS AND LIMITATIONS OF TESTING
The client acknowledges that potential risks and limitations associated with laboratory testing may include but are not limited to:
• Discomfort during sample collection
• Inconclusive or inaccurate results
• Delays in processing or reporting
• Variability in laboratory reference ranges
• Misinterpretation if results are used outside their intended context
The client voluntarily accepts these risks.
6. THIRD-PARTY LABORATORY DISCLAIMER
Laboratory tests are processed and analyzed by independent laboratories. The practitioner and practice are not responsible for:
• Laboratory errors
• Lost or delayed samples
• Shipping delays
• Laboratory processing errors
• Result reporting delays
Any concerns regarding laboratory processing must be directed to the laboratory performing the analysis.
7. TELEHEALTH CONSENT
The client agrees to participate in telehealth consultations using electronic communication technologies such as video conferencing, email, or telephone.
Telehealth services may include consultation, education, review of laboratory results, and wellness guidance.
The client understands and acknowledges:
• Telehealth services may have limitations compared to in-person visits.
• Technical difficulties may occur during telehealth sessions.
• Electronic communication carries some risk of privacy breaches despite reasonable safeguards.
• Telehealth is not appropriate for emergency situations.
If the client is experiencing a medical emergency, they agree to contact emergency services or seek immediate medical care.
8. PRIVACY AND HIPAA ACKNOWLEDGMENT
The practice is committed to protecting the confidentiality of client health information.
Client information may be collected, stored, and shared as necessary for the following purposes:
• Scheduling and providing services
• Ordering laboratory testing
• Communicating with laboratories
• Maintaining health records
• Billing or payment processing if applicable
Protected Health Information (PHI) will only be disclosed as permitted by law or with the client’s written authorization.
Clients acknowledge that electronic communication methods such as email, telehealth platforms, and client portals may be used and may carry inherent privacy risks.
9. LIMITATION OF LIABILITY
To the fullest extent permitted by law, the client agrees to release, indemnify, and hold harmless the practitioner, the practice, and its lab partners, and affiliates from any claims, damages, or liabilities arising from:
• Participation in wellness consultations
• Use or interpretation of laboratory testing
• Implementation of wellness recommendations
• Telehealth services
• Actions taken based on educational information provided during consultations
10. NO GUARANTEES
The client acknowledges that individual health outcomes vary and that no guarantees have been made regarding results from services, recommendations, or laboratory testing.
11. PAYMENT AND CANCELLATION POLICY
Payment for services is due at the time services are scheduled unless otherwise agreed upon.
All payments are final and non-refundable. This includes all services, programs and functional lab testing. No refunds will be issued for unused sessions, partially completed programs or purchased lab tests.
Sessions may be rescheduled with at least 24 hours notice. Any cancellations or rescheduling requests made within 24 hours of the scheduled session may be forfeited and not eligible for rescheduling.
By purchasing services or programs, you acknowledge and agree to these terms.
12. BREATHWORK ACKNOWLEDGMENT
I understand that breathwork is a somatic and experiential practice that may involve physical, emotional, and energetic responses. I acknowledge that I am responsible for listening to my body and participating at my own pace.
I understand that breathwork is not a substitute for medical or psychological care, and I assume full responsibility for my participation before, during and after the session.
For breathwork sessions, I may be required to review and sign an additional waiver prior to participation.
13. ACKNOWLEDGMENT AND CONSENT
By signing below, the client confirms that they:
• Have read and understand this agreement
• Have had the opportunity to ask questions
• Voluntarily consent to participate in integrative wellness services
• Consent to telehealth services when applicable
• Consent to functional laboratory testing if they decide to do it