The following two scope of practice statements* are presented in compliance with the WA State Department of Health:
* LMP/LMT/RD/CN licenses/registrations/certifications do not include training or certification for Colon Hydrotherapy.
* LMP/LMT/RD/CN licenses/registrations/certifications do not include training or certification for Electrolymphatic Therapy.
I legally agree to all of the following terms of the online scheduling system, hereafter referred to as “system”, and with regards to my business and health care relationship with the Tummy Temple. I realize that I have a choice to not agree to these terms and to choose another health care organization for my health care.
I understand I use this system at my own risk and it is my responsibility to only use the system if I understand what I am doing. This system is being offered as a convenience and I do not need to use it to book appointments. Reminder emails, as well as reminder calls, are a courtesy and whether or not I receive them I am still liable for appointments that I make. I understand that the Tummy Temple does not staff a help desk to support this system outside of Monday through Friday 9 am to 5 pm. I understand that if I have problems with the system it may take up to 24 hours, or longer (especially during a weekend), to get a response.
I understand that due to the possibility of error I should start using this system only to book appointments at least one week out in case I have confusion or problems using this system.
If an appointment is booked through my personal account, even accidentally, then I am financially responsible for that appointment.
I agree that I will pay for my sessions at the time services are rendered and that the credit card on file may be used in cases whereby payment is not on hand or there are insufficient funds to cash a check. There will be a $30.00 fee charged to my credit card on file if my check is bounced due to insufficient funds.
Rates may change without notice.
I agree to cancel and/or reschedule my sessions at least 24 hours in advance of my scheduled appointments by using this system, calling or leaving a voicemail message at 206-729-6211. If I fail to do so or don’t show for my session I will pay the full session fee via my credit card on file. The online scheduling system will not allow you to make any changes to appointments during the 15 hours prior to a specific appointment.
Cash, checks, and credit cards (Master Card, Discover & Visa) are acceptable methods of payment.
I understand that if I provide my credit card as a backup form of payment in order to set up another persons account that I am liable for payments they are unable to, or do not, make related to appointments scheduled or products purchased by or for them. I understand that my credit card information will remain on the other person’s account until I remove it or the other person replaces it with their own credit card information. I understand that I may call the Tummy Temple at any point in time to confirm if my card is still on the account.; I understand that it is my responsibility to remove my credit card information from their account by calling 206-729-6711 and speaking with an office administrator or manager directly and emailing that person as written confirmation of the request. If charges accrue prior to removal of the credit card information from the account then I am still liable for payment.
I commit to the Tummy Temple that all information I provide is truthful. I commit that I am not withholding any information that may put myself, the Tummy Temple, other clients of the Tummy Temple, or any employee of the Tummy Temple at harm or at risk from a health and/or legal standpoint.
I understand that I use the Tummy Temple services at my own risk. I recognize that it is my responsibility to address all medical health conditions with medically licensed doctors; ie. Naturopathic Doctors. I will not seek treatment, advice or cures from non-doctor practitioners at the Tummy Temple.
I understand that the information divulged during an appointment is confidential and that the practitioner has signed a Notice of Privacy (NOP) to protect my confidential information.
I authorize The Tummy Temple to contact me via the contact information I provide for any reason related to my relationship with the Tummy Temple.
I authorize The Tummy Temple practitioners to collaboratively support my health needs with other practitioners internal to The Tummy Temple.
I authorize the Tummy Temple practitioners to collaboratively support my health needs with my other health care providers outside of the Tummy Temple as I disclose verbally or in written form or to those that have referred me.
I know that I am responsible for my own health and actions and only I can heal myself. Practitioners, therapies, services and products are only tools I employ or purchase to help me.
I understand that my practitioner may not be a doctor. If they are a doctor they will be listed on the website with their legal credentials as well as on their business card. As well none of our therapists are licensed psychotherapist. If the therapist is not a doctor then any therapies, conversations or sessions used to support my wellness do not infer or intend to diagnose, treat or cure physical, mental, emotional or spiritual disorders.
Before receiving colon hydrotherapy, I agree to always review the contraindications, and provide a copy of a prescription from my doctor to my therapist regarding any contraindications that apply to me.
Contraindications may be found by copying and pasting the following web address into your browser and clicking on the enter key.
I understand that sexual intimacy is never appropriate with my practitioner.
I understand that the terms may be updated without notice to further protect all parties involved. I understand that I am bound to the terms posted publicly at the time appointments were made. I agree to review the terms before each new appointment to ensure my understanding and compliance. If major changes are made I agree to allow the Tummy Temple to email me with these changes if they so choose.
A copy of these terms is always posted for the public.
The following is the Tummy Temple Arbitration Agreement related to all services offered at the Tummy Temple:
Article 1: Agreement to Arbitrate:
It is understood that any dispute as to medical and non-medical malpractice, including whether any services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by state and federal law, and not by a lawsuit or resort to court process, except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
Article 2: All Claims Must be Arbitrated:
It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, as to whether this agreement is unconscionable, and any procedural disputes, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment, products or services provided by the health care provider, including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. This agreement is intended to bind the patient and the health care provider and/or other licensed health care providers, preceptors, or interns who now or in the future treat the patient while employed by, working or associated with or serving as a back-up for the health care provider, including those working at the health care provider’s clinic or office or any other clinic or office whether signatories to this form or not.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider, and/or the health care provider’s associates, association, corporation, partnership, employees, agents and estate, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages.
This agreement is intended to create an open book account unless and until revoked.
Article 3: Procedures and Applicable Law:
A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days, and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit.
Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action, and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration.
The parties agree that provisions of state and federal law, where applicable, establishing the right to introduce evidence of any amount payable as a benefit to the patient to the maximum extent permitted by law, limiting the right to recover non-economic losses, and the right to have a judgment for future damages conformed to periodic payments, shall apply to disputes within this Arbitration Agreement.
The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement.
Article 4: General Provision:
All claims based upon the same incident, transaction, or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.
Article 5: Revocation:
This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and, if not revoked, will govern all professional services received by the patient and all other disputes between the parties.
Article 6: Retroactive Effect:
This agreement does not cover services rendered before the date it is digitally signed through execution of setting up an account in the online scheduling system and/or filling out an intake form or booking an appointment. I understand that I may make a copy of this Arbitration Agreement for my records and it is my responsibility to do so.
BY AGREEING TO THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL NON-MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
INFORMED CONSENT TO TREAT:
I hereby request and consent to the performance of treatments, services and other procedures within the scope of the practice of all services provided by Tummy Temple practitioners on me (or on the patient for whom I am legally responsible) by the practitioners who now or in the future treat or service me while employed by, working or associated with or serving as back-up for the those working at the clinic or office listed below or any other office or clinic, whether signatories to this form or not. I understand that methods of treatment may include, but are not limited to colon hydrotherapy, massage, Naturopathic medicine, Electrolymphatic Therapy, Decongestive Lymphatic therapy, nutrition, restorative Yoga, craniosacral therapy, homeopathy, cupping, electrical stimulation, and Registerd Dietician Consultations. I understand that the herbs or supplements may need to be prepared and the teas consumed according to the instructions provided orally and in writing. The herbs and supplements may have an unpleasant smell or taste. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the consumption therein.
I have been informed that all therapies provided at the Tummy Temple are generally safe. With that said, each person is unique in their current health state, genetics, allergies, history of trauma; surgeries and ability to handle any given therapy. With all body therapies there is a possibility of nausea, aches, pains, emotional release and instability, uncomfortable symptoms and the uncovering of deeper issues. I understand that these risks and many others exist that are unpredictable and potentially unavoidable. I understand that results vary and may not be guaranteed. I will immediately notify a member of the clinical staff of any unanticipated or unpleasant effects associated with the therapies received.
Special Note: The Tummy Temple has a proud history of ZERO (0) injuries to customers.
By voluntarily agreeing, I show that I have read, or have had read to me, the above consent to treatment and support, have been told about the risks and benefits of therapies I will be receiving, and have had an opportunity to ask questions. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment and for any wellness services I receive.