Gut Restoration Program Agreements, Authorizations & Acknowledgments
I authorize Dr. Katelynn Nardulli, licensed chiropractor in the Commonwealth of Pennsylvania and Functional Diagnostic Nutrition Practitioner, to provide treatment for myself, or my minor child. I understand that I am seeking professional advice from Dr. Nardulli, for consultation purposes only. I understand that Dr. Nardulli’s practice focuses on overall wellness, nutrition, and lifestyle modifications that may include functional, holistic, complementary and integrative approaches.
I understand that although Dr. Nardulli is trained in traditional chiropractic practices and nutrition, her services and recommendations are based on non-traditional, or non-conventional services, often referred to as complementary, alternative, holistic or Functional Medicine. This approach to healing and health may entail the use of other services that may not be offered or recognized by those physicians in the medical community who practice solely, traditional medicine. Many of these services may include, but are not limited to, nutrition, health counseling, herbal consultation, and mind-body approaches, that may not be recognized as customary medical practices. Many of the approaches have been practiced for many years, but may be considered investigational, experimental and may not be approved by the Food and Drug Administration and other regulatory agencies.
Dr. Nardulli will help me locate the root cause of my ongoing health challenges with a goal of improving my overall health. To achieve this goal, I understand that Dr. Nardulli will utilize functional lab tests that target my primary health concerns and specific systems of health to evaluate the function of these systems. Dr. Nardulli will then evaluate functional lab test results and clinically correlate them with my medical history. Based on my unique results and current health status, I understand that Dr. Nardulli will customize holistic health rebuilding programs for my benefit including holistic health rebuilding programs such as recommendations on diet, rest, exercise, detoxification, stress reduction and supplements.
I understand that herbs, botanical products and supplements are available over the counter and are generally considered safe, based on their long history of use by many cultures, but many have not been tested using conventional study designs. Although rare, any product can be detrimental, particularly if I am allergic to them, and this could lead to serious consequences. Interactions, both commonly known and some unknown, between conventional drugs, other herbs or supplements, and some medical conditions, exist. This could result in reduced or increased effects of other medications or other negative effects. It is therefore vital, that before introducing any new products or healthy lifestyle changes I discuss these products or changes with my primary care physician and/or any other treating provider who has prescribed pharmaceuticals that I am currently taking.
I understand that as part of the Gut Restoration Online Program, I will need to provide a detailed health history and complete a gut functional lab test (GIMAP by Diagnostic Solutions). The results of this test will be provided to me along with an in-person appointment or video-call that explains the results and provides recommendations for a customized 90 day supplement protocol in a Results and Recommendations Session. As a participant, I will also receive additional online educational modules including holistic recommendations in the areas of diet, rest, exercise, detoxification and stress reductions to further support healing and promote better gut health.
I understand that it is my responsibility to provide a detailed health history by completing the required health history intake form provided to me upon enrollment in the Gut Restoration Program. I also understand that it is my responsibility to complete the GIMAP Functional Gut Test by Diagnostic Solutions that will be provided to me upon enrollment. I understand and acknowledge that failure to provide this detailed health history or failure to complete the functional gut test within 12 weeks after enrolling the Gut Restoration Online Program will result in forfeit of this portion of the program with no partial or full monetary refunds.
I understand there is a cancellation fee of $250 for missed appointments, both in-person and video appointments included, that are not cancelled more than 24 hours in advance. This fee must be paid prior to next appointment. I understand that it is my responsibility to schedule and complete the Results and Recommendations Session within 12 weeks after enrolling in the Gut Restoration Online Program.
I understand that Dr. Nardulli is NOT my primary care physician (PCP) and is NOT responsible for the diagnosis and treatment of any particular disorder, but instead is offering guidance for my overall health, regarding nutrition, wellness and soundness of mind and body. I understand that I must maintain a PCP to continue with all available conventional measures to attend to any medical condition for which I require continued monitored medical care.
I understand that should I have an adverse reaction, and if it is serious, I will seek emergency care immediately. I understand that Dr. Nardulli does not treat urgent or emergency conditions and that I should seek help at a qualified medical facility or my own doctor. I will also report to her, any and all unfavorable reactions that occur. I understand that Dr. Nardulli is completely office-based and she does not admit to a hospital, is not affiliated with any hospital or insurance company, and she does not provide emergency, on-call services.
I understand that due to the nature of the educational content provided in the online portion of this program, that the Gut Restoration Program is non-refundable. I also agree not to share access to this online educational content with those not enrolled in the Gut Restoration Program as this program is the intellectual property of Dr. Katelynn Nardulli. I also agree not to reuse or repurpose this intellectual property in the Gut Restoration program as my own for monetary or non-monetary gains.
I also understand that Dr. Nardulli does not participate in any health insurance plans, including Medicare, and her services will NOT be billed to OR submitted for reimbursement by health insurance companies or Medicare.
I understand that there is no guarantee of results or outcomes of any diagnosis or treatments rendered by Dr. Nardulli, as the practice of the healing arts is not an exact science. I agree that I will take responsibility for my health and well-being by following my personal treatment plan suggested by Dr. Nardulli. I will also discuss the advice and ideas of Dr. Nardulli during my sessions. Her treatment plans are meant to further my own health, and not for the purpose of treatment or anything else. I may not benefit from the treatment plan designed for me, especially if I do not follow the recommendations. I do not hold Dr. Nardulli responsible for less than satisfactory results.
I have read and understand the nature of the services provided by Dr. Nardulli. It is my prerogative to revoke, in writing, at any time the authorizations contained in this document. Such revocation, does not affect my financial responsibility to pay for services already provided to me by Dr. Nardulli and her staff. I also declare that I am here to receive health care only, and for no other reason.