Thank you for making the decision to purchase a custom nutritional supplement. Dr. Michael Wald has recommended this supplement to you for one or more of the reasons below.
I have sought the medical and health care services of Dr. Michael Wald and/or Blood Logic, Inc. for my personal healthcare or for my child or children who are minors. I understand that this Dr. Wald may employ/use some diagnostic and treatment methods that are known as complementary, alternative, or holistic, and they may not be covered by my insurance plan, or generally accepted by mainstream healthcare as the standard-of-care for my condition(s).
The terms complementary, alternative, and holistic refer to therapies that may include, but are not limited to, dietary and nutritional supplement advice, and various diagnostic/testing procedures and chiropractic care. Furthermore, the information gained from laboratory and other tests may be interpreted differently from mainstream medical doctors for educational purposes. Approaches for improving my general health and nutrition may be based upon the tests/evaluations and philosophies of complementary healthcare and may or may not be consistent with mainstream medical tests/evaluations and philosophies. Foods, vitamins, minerals, enzymes, herbs, and other nutritional approaches may be advised as a stand-alone therapy or as adjunctive to medical therapies. Not all vitamin-drug (medication) reactions can be predicted, have been well-proven or may not apply to you; we reserve the right to apply our independent judgment regarding the use of vitamins, minerals, herbs and other nutritional products with or without medications that you may be taking or will take, or that may be recommended by us.
It is your responsibility to follow our supplement (nutritional) advice exactly and to inform us of any changes you make on your own, or at the advice of health care providers as adverse or unintended or dangerous consequences may result. Dr. Michael Wald , Blood Logic, Inc. and our office employees make no representations, claims, or guarantees regarding the efficacy of our treatment recommendations. The treatments we recommend are based upon a combination of our clinical experience and knowledge of scientific and medical literature. With this information, individualized treatments may be offered and applied as either adjunctive (complementary) or primary treatments for various symptoms and disease states.
By signing this informed consent you agree to hold harmless Dr. Michael Wald and/ or Blood Logic, Inc. and its employees from all professional and personal liability. You agree to be responsible for all legal costs and fees that may result from action(s) on your part or on the part of your representative(s) against us. If a legal case is brought against us, you agree that we shall be judged by the standards and principles of complementary, alternative, and/or holistic medicine and not the standards and principles of consensus conventional medicine. You have the right to have this consent reviewed by your lawyer before accepting any medical and/or nutritional services from this office. If you are investigating our office you are here by requested to reveal the purpose of your investigation at the beginning of your first appointment with Dr. Wald otherwise you agree to pay all legal and other fees spent to respond to your or your employers legal or other forms of charges against us. If any portion/part of this agreement is deemed unenforceable all other portions and aspects of this agreement shall remain in force.
Our office makes available nutritional supplements and other health products. You are in no way obligated to purchase these products from our office or any other specific location or company. You may freely choose to purchase such products from any source(s) as you wish. Dr. Wald profits from the sale of supplements and other products we make available to our patients. Most insurance plans cover services that they consider medically necessary and/or reasonable and customary. Many of our services (nutritional consultations) are often not considered to be necessary by insurance companies based upon their own internal criteria.SIGNATURE ON FILE: I authorize any holder of medical information about me to release to my insurance company and its agents any information needed to determine these benefits or the benefits payable for related services. Your signature, and/or acknowledgement to purchase services and/or products from this website, verifies that you have not been told to discontinue treatments with any other medical specialists or other health care providers. Your signature is being given prior to your accepting any services, advice, and/or recommendations whatsoever from Dr. Michael Wald, and your payment for services will serve as your unconditional acknowledgment of satisfaction with the services provided. This acknowledgment will serve as proof of our policy of no refunds of monies paid to this office in the form of cash, credit card, and personal check or by any other means. It is the responsibility of the patient to follow-up with our office for results of all testing and laboratory procedures. It should not be assumed on the part of the patient that if they are not contacted by Dr. Wald, or its employees, or if the patient does not schedule or keep a consultation, that test results are normal (or without abnormalities), and may not require further medical treatments or advice. Health/ medical recommendations and/or possible referral and additional follow-up may be warranted based upon laboratory testing and evaluations. Please schedule your follow-up appointment at the front desk after each and every consultation or visit to the office. The patient is further notified that their insurance company may not cover some or all tests recommended. The patient assumes full responsibility for the costs of non-covered tests. and consultations. If allowed by law, our office will not provide insurance collection services, but will commonly make reasonable attempts to provide letters of medical necessity and answer correspondences from your insurance company regarding your treatments. By entering your signature below you are acknowledging that you understand all terms, verbiage (language) and concepts herein. I understand this consent agreement and have executed it freely and willingly. If any portion of this new patient paperwork is considered unreasonable or non-enforceable in a court of law, all other aspects of this agreement shall remain in force.
YOU ALSO AUTHORIZE DR. WALD TO USE YOUR CREDIT CARD ON FILE AS PAYMENT FOR ANY SERVICE AND/OR PRODUCT THAT CARRIES A BALANCE WITHOUT PRIOR NOTICE OR ADDITIONAL APPROVAL. DR. WALD WILL APPLY (sign) YOUR NAME TO ALL CREDIT CARD CHARGES AS A WRITTEN NAME OR SIGNATURE.