EPIGENETIC CONSULTATION CONSENT

Epigenetics is the study of changes in DNA that do not involve alterations to the underlying DNA sequence. 

After completion of a genetic test, Lisa Koche, M.D. (“Dr. Koche”), a provider at Spectra Healthcare Associates, P.A. (“Spectra”), will consult with the Client for thirty (30) minutes to discuss the results of the genetic test and to answer any questions that I (hereinafter referred to as “The Client”, “the client”, “Client”, and/or “client” may have about the genetic test results. The Client understands the following with respect to this consultation:

1. The Client understands that the consultation is for educational purposes only.  Neither Dr. Koche nor Spectra will provide any medical advice or treatment with regard to the Client’s genetic test.  The consultation is based on current information and data which is subject to change and may not be agreed upon by others.  It is understood that any recommended alterations in lifestyle may, but are not guaranteed to, trigger genetic responses. The Client agrees to contact the Client’s own health care provider(s) to obtain any and all medical advice or treatment.
2. The Client acknowledges that Dr. Koche may or may not recommend that the Client take certain dietary supplements as part of the consultation.  These dietary supplements are not considered pharmaceuticals and may be bought from vendors recommended by Spectra or from any other vendor chosen by the Client.  The Client understands that, if he or she chooses to purchase from a vendor recommended by Spectra, Spectra and/ or Dr. Koche may receive a financial incentive for that purchase.  The Client also understands that this agreement does not obligate or require the Client to purchase any dietary supplements from either Spectra or Dr. Koche.
3. There are potential risks associated with the use of online technology formats, including, but not limited to deficiencies or failures of the equipment and/ or security protocols resulting in a breach of privacy of PHI.  The Client understands that PHI may be lost due to technical failures and agrees to hold Spectra and Dr. Koche harmless for any such loss.
4. The Client understands that the laws that protect privacy and confidentiality of medical information apply to these consultations. The Client understands that no information obtained during the consultations which identifies the Client will be disclosed to other entities without the Client’s consent or as required by applicable law.  The Client has the right to inspect all information obtained and recorded in the course of a consultation.
5. The Client understands the alternatives to use of an online technology format as they have been explained to him or her. The Client understands that, if others are present at Client’s location during the Client’s consultation, the confidentiality of the Client’s consultation may be compromised.
6. The Client understands that the genetic test and consultation are cash pay services which must be paid for prior to scheduling.  These services are NOT covered by insurance and Dr. Koche is not ordering these tests on behalf of the patient. Client understands that the company that performs the test is completely independent from and unrelated to Spectra and Dr. Koche.
7. The Client agrees to NOT submit a claim to his or her insurance carrier for the consultation. The Client understands that Spectra and Dr. Koche (inclusive of all related parties) will NOT submit any claims for services to The Client’s insurance carrier.
8. The Client understands that the Spectra office and Dr. Koche are located in the state of Florida and, thus, all disputes, if any, arising from the consultation will be resolved in Florida, and Florida law will govern any such disputes.
9. The Client has been advised of all the potential risks, consequences and benefits of consulting with Dr. Koche in an online technology format for an educational consultation relating to Client’s genetic test. The Client’s has had the opportunity to discuss and ask questions to Dr. Koche about the information provided above.  All the Client’s questions have been answered, and he or she understands the written information provided above.

By completing the order on this page, I (as “Client”), consent to consult with Dr. Koche via an online technology format regarding the results of my genetic test for educational purposes only. I understand that I am not receiving any medical advice or treatment and that I should contact my own health care provider(s) to address or obtain treatment for any medical issues. I represent, warrant, and agree that I am authorized to consent to the rendition of the epigenetic consultation services described herein. I understand that I may revoke my consent in writing, and if I later revoke my consent, Spectra will not decline to provide future consultations to the undersigned Client under conventional, in-person methods.