The intention of this consent form is to help patients, clients, and authorised representatives become better informed so that they may give or withhold consent to undergo diagnosis and treatment after having an opportunity to discuss health concerns, including potential benefits and risks, and treatment alternatives.
Functional Medicine is the application of science in the promotion of health. We use a wide range of tools to assess and identify potential nutritional imbalances and understand how these may contribute to an individual’s symptoms and health concerns. Treatment plans are formulated primarily using an evidence-based diet and lifestyle-medicine approach. The recommendations focus on diet and nutrition, physical movement, mental well-being, adequate sleep and lifestyle adaptations to improve metabolic functioning, nutritional sufficiency and reduce stress.
Functional Medicine is relevant for individuals with chronic conditions, as well as those looking for support to enhance their health and well-being.
Functional Medicine Doctors consider each individual to be unique and recommend personalised nutrition and lifestyle programmes rather than a ‘one size fits all’ approach. We will never recommend Functional Medicine Therapy as a replacement for medical advice and always refer any patient with ‘red flag’ signs or symptoms to their own GP. We will also frequently work alongside and communicate with other medical and allied health professionals involved in the patient’s care to explain any therapy or protocols that have been provided.
The Functional Practitioner requests that the Patient notes the following:
1)The degree of benefit obtainable from Functional Medicine Therapy may vary between clients/patients with similar health problems and following a similar therapy programme.
2) Functional advice will be tailored to support health conditions and/or health concerns identified and agreed between both parties.
3) Functional Medicine advice is not a substitute for professional medical advice and/or treatment.
4) Your Functional Medicine Practitioner may recommend food supplements and/or Functional Testing as part of your therapy programme and we pass that discount off to our patients in the form of the codes that you will receive from us. We do retain a small fee, simply to cover our admin costs.
5) This document only covers the practice of Functional Therapy within this consultation, and your practitioner will make it clear if he or she intends to step outside this boundary.
The Patient understands and agrees to the following:
7) I am responsible for contacting my GP about any health concerns.
8) I give permission for you to contact my GP regarding any agreed aspects of my case.
9) If I am receiving treatment from my GP, or any other medical provider, I should tell him/her about any Functional strategy provided by my Functional Practitioner. This is necessary because of any possible reaction between medication and the programme.
10) It is important that I tell my Functional Practitioner about any medical diagnosis, medication, herbal medicine, or food supplements, I am taking as this may affect the programme.
11) If I am unclear about the agreed Functional Medicine programme/food supplement doses/time period, I should contact my practitioner promptly for clarification.
12) I must contact my practitioner should I wish to continue any specified supplement programme for longer than the originally agreed period, to avoid any potential adverse reactions.
13) Recording consultations using any form of electronic media is not allowed without the written permission of both me and my Functional Practitioner
RE-SCHEDULING & CANCELLATIONS:
Sessions may be re-scheduled by contacting Dr Gayetri’s Practice preferably via your patient portal, but also on 0207 112 8831 or via email to [email protected].
On booking you will be invoiced for the payment of your consultation/ initial phase of your package. Secure payment is taken online.
Booking and Cancellation Fees:
We require 7 days to change the appointment date.
Secure credit card payments are taken online via Stripe.
Once you have booked an appointment you will receive an invoice for the payment of your consultation or the initial phase of your chosen package. We usually require a minimum of 1 week to change an appointment date. If a clinic session is cancelled within 1 week of the scheduled appointment or for on-the-day non-attendance then fees will be as follows:
Doctor appointment Cancellation Fee – £250
Patients who repeatedly miss appointments or reschedule at short notice more than twice may be asked to pay the full fee. Please bear in mind that we will typically see only 2-3 patients a day, and a last-minute cancellation is not often possible for us to fill.
TIMELINESS:
Please be on time for your appointment, if you are late your session may be cut short. If you know you are running late please contact us on 0207 112 8831 and we will decide how best to go forward with the remaining time. In some cases, the session may be forfeited.
OTHER CONTACT :
Please try to keep the majority of contact via the Patient portal. You can do this online. This is because emails are easily overlooked or lost or end up in a spam folder. The patient portal offers a secure and easy way for us to manage patient contact and records in a secure and organised manner.
Regarding current patient queries between appointments, we will gladly address them during your subsequent consultations. To ensure patient safety and comply with professional guidelines, we are unable to handle email queries. If you suspect any adverse reactions to supplements, kindly discontinue their use, make detailed notes, and we can discuss this matter during your next consultation. The same applies to specific food reactions. Unless you receive specific guidance to do otherwise, please continue with the supplements as advised until your next appointment.
For more accurate and effective communication, we encourage direct discussions during our short 15-minute appointments with your Doctor. If you wish to schedule one, kindly provide your availability, and we will be happy to book it for you.
Should you have a specific need for email correspondence, it can be arranged, but please note that it will incur a cost based on pro-rata professional hourly rates. Our doctors and Nutritional therapists aim to return your email within 72 hours on weekdays.
PROGRAMME DURATION:
You get the best results if you work consistently and steadily towards your goal. With that in mind, 3-month (12-week) packages have an expiry date of 4 months (16 weeks) from the Initial Consultation session.
This allows for flexibility to work around holidays and other contingencies but still helps you keep focused, accountable and on track. Please note that packages do have an expiry date.
Sessions skipped during this time and not taken before the expiry date are not refunded.
PAYMENT:
All Services must be paid for in full by BACs/bank transfer or card payment at least 72 hours in advance of the initial consultation appointment.
PAYMENT PLANS:
We do offer payment plans for those who choose one of our packages. Please inquire further to discuss the available options.
REFUNDS:
If you have commenced a programme and wish to cancel prior to the end of all scheduled services offered within the programme, you shall be obligated to pay all fees accrued prior to the effectiveness of your cancellation. Dr Gayetri’s Practice reserves the right to include fees for all preparatory work and research undertaken in addition to the scheduled contact dates for consultations and calls.
Dr Gayetri’s Practice reserves the right to decline to provide the Services to you for any reason and will refund any amounts prepaid by you for Services not received.
OTHER COSTS:
The cost of supplements and tests is not included in consultation fees.
Supplements:
We provide personalised recommendations regarding the use of these substances in order to support the physiological and biomechanical processes of the human body. Although these products may also be suggested with a specific therapeutic purpose in mind, their use is chiefly designed to support aspects of metabolic function. The use of nutritional supplements may be safely recommended for patients already using pharmaceutical medications (drugs), but some potentially harmful interactions may occur. For this reason, it is important to keep all healthcare providers fully informed about all medications and supplements, herbs, or hormones you may be taking.
As a service to you, we will recommend supplements and suppliers. You are under no obligation to purchase these specific supplements.
We only recommend products from manufacturers who have gained our confidence through considerable research and experience. We determine quality by considering: (1) the quality of science behind the product; (2) the quality of the ingredients themselves; (3) the quality of the manufacturing process; and (4) the synergism among product components. The brands of supplements that we recommend are those that meet our high standards and tend to produce predictable results.
While these supplements may come at a higher cost than those found on the shelves of health food stores, the value must also include assurance of their purity, quality, bioavailability (ability to be absorbed and used by the body), and effectiveness. You are not guaranteed the same level of quality when you purchase your supplements online or at a retail store. We are not suggesting that such products have no value; however, given the lack of stringent testing requirements for dietary supplements, product quality varies widely.
If you have concerns our staff is available to talk with you.
Functional Medicine Laboratory Testing
The purpose of functional medicine laboratory testing is to evaluate nutritional, biochemical, or physiological imbalances and to determine the need for medical referral. These lab tests are not intended to diagnose disease. We utilise conventional lab tests, as well as, other labs commonly used in functional medicine care.
Functional medicine assessment is designed to assist our doctors and other healthcare providers in finding the underlying causes of your condition. Functional medicine has evolved through the efforts of scientists and clinicians from the fields of clinical nutrition, molecular biology, biochemistry, physiology, conventional medicine, and a wide array of scientific disciplines. Functional medicine evaluates the body as a whole, with special attention to the relationship of one body system to another and the nutrient imbalances and toxic overload that may adversely affect these relationships.
Other healthcare providers may or may not agree with the necessity for—or our interpretation of—these tests. If you have any questions or concerns, please discuss them with our doctors.
THIRD PARTIES / OTHER CONFIDENTIALITY, GDPR AND DATA PROTECTION :
GDPR
Information provided for the purpose of this Functional Medicine Consultation will be stored in line with legal requirements. Seven years for adults and seven years after a child’s 18th birthday. All information will be stored in locked storage and on the F365 database. Each client has the right to request the information held on the F365 database be removed.
As part of your healthcare:
Dr Gayetri’s Practice will only give your personal information to third parties where the law either requires or allows it. Otherwise, your practitioner may want to share your sensitive information with third parties to support your ongoing healthcare, however if we do not receive this consent from you, we will not be able to coordinate your healthcare with that provided by other providers which means the healthcare provided by us may be less effective.
We may also need to share your contact information with biochemical testing companies to order tests as part of your healthcare, some of which may be from outside of the European Union. If we do not receive this consent from you, we will review alternative tests from providers based within the European Union
PERMISSION TO CONTACT GP AND THIRD PARTIES IN AGREED CIRCUMSTANCES:
I give permission to contact my GP regarding agreed aspects of my case.
Also in the event that your GP has any questions, concerns or issues with your Functional Medicine program. We may contact them if we feel that it can help facilitate you getting some test, treatment etc via your GP or to explain your Functional Medicine Therapy to your doctor, or some other exceptional circumstance.
Case Histories:
Your practitioner seeks to continuously improve our practice through professional development, a key part of which is sharing case histories with our peers through clinical supervision, online forums and discussion groups. Your name, address and contact details will never be shared.
Your practitioner would like to share your case history with peers for educational purposes. This could be through conferences, lectures, online forums, and publishing in medical journals, trade magazines or online professional sites. Your name, address and contact details will never be shared.
You can withdraw your consent to the above at any time by emailing [email protected]
NEWSLETTER / EMAIL LIST:
I add all new clients to my email list so you can receive my monthly newsletter with bits on nutrition, health, lifestyle, recipes, ebooks etc. You may choose to unsubscribe at any time by selecting the ‘Unsubscribe’ button at the bottom of emails.
VIDEO CONSULTATIONS:
I am choosing to receive Functional Medicine Consultations sessions with Dr Gayetri’s Clinic via the Zoom (https://zoom.uk/). By choosing this option, I understand:
• Zoom is an online communication tool allowing face-to-face video, voice, or text-based chat/dialogue. Zoom calling is encrypted to protect sensitive information. For more information on how Zoom keeps its client’s information private, please visit and review the information at the links below.
→ https://zoom.us/docs/doc/
• Zoom software is available on any computer or smartphone/tablet. Ensure that your device is password protected and only you have access to the password. In addition, use a password-protected private Internet connection when on a Zoom call. You may wish to choose a username that does not identify you by name to ensure more privacy.
• Any Internet-based communication is not 100% guaranteed to be secure/confidential. Your practitioner has made every reasonable effort to implement technical security measures that reduce the risks of a confidentiality breach.
• I have read the privacy and encryption information for Zoom and I agree that Dr Gayetri should not be held responsible if any outside party gains access to Zoom account information or transactions by bypassing online security measures.
• Video sessions are not to take the place of the more optimal in-practice consultations, but are utilized when in-practice sessions are not convenient or possible, and only at the client’s request.
My Responsibilities as the Client:
• I am responsible for ensuring confidentiality by closing other programs on my computer while in a video session, planning ahead to minimise distractions, and not answering calls or text messages while on the Zoom call.
• I also agree to be online five minutes prior to the scheduled video consultation (preferably in a quiet room alone with the door closed). Headphones may be used to increase privacy of session.
Practitioner Responsibilities:
• The practitioner will Zoom call the client at the scheduled appointment time.
• The practitioner will ensure to be alone in their office with a high-quality, password-protected wireless Internet connection.
• The practitioner will ensure all other distractions such as phone calls are eliminated during the video consultation.
• Technical problems may occur. If a call is disrupted, the practitioner will call you back unless technical difficulties persist. In such cases, the session can be continued via phone or rescheduled via phone or email, depending on the client’s preferences.
Please do bear in mind:
All staff are part-time and are not expected to work outside of their allocated hours.
We don’t have the resources to offer any form of emergency medical service. All acute illnesses should be referred to your GP.
Client agrees to:
1 – Informed Consent: acknowledges the right, opportunity, and responsibility to ask questions and to become informed regarding the clinician’s diagnostic and treatment recommendations to his or her satisfaction. The patient acknowledges that all questions asked have been fully answered by the clinician.
2 – Potential Risks: acknowledges and accepts that there are risks to the diagnosis and treatment measures that fall within and outside the conventional standard of care and that these risks may include: unintended exacerbation of symptoms, new symptoms, allergic and other unintended injury and side effects from exercise, lifestyle modifications, dietary modifications, herbal and nutritional supplements, injected or intravenous therapies, hormonal therapies, adverse interactions with drugs, herbs and/or nutrients. The specific risks associated with the proposed procedures have been explained to the patient and/or the patient’s representative.
3 – No Guarantee of Potential Benefits: acknowledges that treatment may result in the restoration of health and optimal functional capacity, relief of pain and symptoms, injury and disease recovery, and prevention or reversal of disease or disease progression, but ALSO acknowledges that no expressed or implied guarantees or representations can or have been made by the clinician or any affiliated staff regarding the cure or improvement of the patient’s condition.
4 – Limitations of Full Disclosure: acknowledges that the clinician cannot know or anticipate and explain every possible risk or complication and that the patient or representative willingly chooses to rely on the clinician to exercise their best judgment within the bounds of their licensure for any of the above.
5 – Responsibility to Report Possible Pregnancy: agrees to alert the clinician should she suspect that she is or may be pregnant in acknowledgement that some of the diagnostic or therapeutic techniques could present risks to a pregnancy.
6 – Disclosure Coverage: acknowledges and agrees that the consent form will cover the entire course of treatment for the present condition and for any future condition(s) for which treatment is sought.
7 – Willing Participation: understands that the patient is free to discontinue participation in any and all aspects of the medical care provided by the clinician at any time and that the patient or representative is responsible for informing the clinician of the adherence to or discontinuation of any and all aspects of care and that the choice to discontinue treatments may create the risk of adverse effects for which the patient or representative bears full and sole responsibility.
8 – Clinician Collaboration: Understand that the clinician may consult with preceptors, clinical student residents, and colleagues related to the care provided and that the patient or the patient’s authorised representative has the right to decline their presence or involvement during any aspect of the patient’s care.
9 – Agreement to be Contacted: understand and accept that the clinician or affiliated staff may contact the patient or representative (e.g., by phone, email, voicemail, SMS text message) to consult or exchange information related to the patient’s care.
10 – Remote Consultations: at times, consultation may be provided remotely and without direct contact with the clinician. In such cases, the patient or their representative agrees to maintain direct contact with a licensed healthcare provider that is appropriate for the patient’s age, gender, and known or suspected health conditions.
11 – Medical Record Keeping and Privacy: understand that records of the health services provided will be kept in line with legal requirements. Seven years for adults and seven years after a child’s 18th birthday. The patient or representative also acknowledges that information within the record may be analysed for research purposes and that in such cases, the patient’s identity (name, address, exact birth date) will be kept confidential. Otherwise, this record will be kept securely and confidentially and without release to others unless so directed by the patient or representative, or as may be required by law or as necessary for insurance claims or other payment processing.
12 – Patient’s Responsibility to Disclose Information: understands that the patient bears full responsibility for any adverse effects experienced during or after the course of treatment that were reasonably deemed to be caused or related to a deficit in the full, accurate, and timely disclosure of symptoms and other medical information to the clinician to the best of the patient’s or representative’s ability.
13 – Responsibility for Payment: understands that some or all of the recommended diagnostic and treatment measures may fall outside the conventional standard of care and may not be approved or covered by the patient’s insurance because the services rendered fall outside the “standard of care,” and in such event, that the patient accepts full responsibility for all associated costs and fees.
14 – Dispute Resolution: agrees that short of overt negligence or malpractice, any complaint or dispute that arises related to the diagnosis or treatment from the clinician will be settled through binding mediation in the country in which the clinician is licensed.
