I agree to pay the $799 fee for the functional medicine testing program which includes food, nutrient and heavy metal testing. Test results include 2 office visits with the doctor as well as a office manual. I give permission to Dr. Tuchinsky or his assistant to administer the test. I understand that this is not covered or reimbursed by insurance and is non-refundable, and no assurance or guarantee whatsoever to cure any condition or illness. This program does not include the cost of any supplements recommended. The clinic and all its employees assume no responsibility for medical conditions requiring the attention of a medical doctor, or necessary adjustments to prescribed medications during or after the completion of testing and dietary alterations. I understand the unpredictable nature of sensitivities / intolerances and related symptoms and that the clinic cannot guarantee any results in the reduction of symptoms. The clinic cannot guarantee that new reactions will not develop in the future. I understand that the clinic does not treat cases of anaphylaxis and I agree to fully disclose all information regarding any life-threating allergies or allergies resulting in anaphylaxis.

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No, I do not have any life threatening allergies.
Yes, I have the following allergies that may cause anaphylaxis

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