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For Creighton Model Services:
I have chosen to learn about the Creighton Model System (CrMS). I have been informed this system is the only family planning method provided at this location. I have decided to learn and use this system. I understand that attendance at all follow-ups is necessary and that the system is 95-99 percent effective when used according to instruction. I understand that my success depends on my commitment to the instructions I am given. If I achieve pregnancy during the course of my use of the system, all paid-for follow ups will be available to me post pregnancy at no additional cost. I do not hold Siena Fertility + Wellness or Elizabeth Madsen, FCP liable for any unplanned pregnancy that may occur while under instruction learning CrMS.
I understand that the recommended follow-up schedule should be followed for optimal learning and assessment of my situation. Follow-ups are recommended at 2 weeks, 4 weeks, 6 weeks, 8 weeks, 3 months, 6 months, 9 months, and 12 months for a total of 8 follow-ups during the first teaching year. My practitioner may recommend additional follow ups during the first year depending on my situation. After that, follow-ups may occur at 6 month or 12 month intervals or as needed depending on my situation. The cost for teaching this system is $40 for a private Introductory Session, $60 for materials and $480 for the first year of sessions, or first 8 follow-ups. This fee can be paid by several methods outlined below. Please select the method of payment you intend to use. Once the full year of teaching (or 8 follow-ups) has been completed and long-term maintenance begins, any future follow-ups will be charged at $60 per session, and additional charts are $3 and sticker sheets are $0.50. Your practitioner will provide you with a receipt with codes for you to submit to your medical insurance, however we cannot guarantee that your plan will cover your service. Health savings accounts and flexible spending accounts can be used for this service usually without any trouble. Payments are to be made out to Siena Fertility + Wellness. We accept online payment via Stripe, PayPal and Quickbooks, Check, Cash or Money Order
_____COMPREHENSIVE PACKAGE. I will pay the entire year (unlimited follow ups, supplies and intro session) in one lump sum. After the first 12 months, I will pay the per follow up rate. If I (client couple) achieve pregnancy during this first year, all unused follow ups will remain available to me post-pregnancy. The amount owed will be $460 under this payment plan, a $120 savings up front.
_____PER FOLLOW-UP PAYMENT. I am informed that typically there are 8 follow-ups over the course of one year to teach the CrMS. In selecting this payment plan, the cost will be $60 per follow-up. The first four follow-ups occur every two weeks, but will spread out over a three-month period beginning with the 5th follow-up.
Once you have selected your payment method and received your supplies, if you choose to discontinue use of the system, we request notice to your practitioner of your withdrawal from use. A final bill will be assessed at that time if there are any outstanding payments to date. There are no refunds offered with the available payment options.
If Creighton Model Services are combined with Feed Your Fertile Body™:
There is a discount of $100 when you combine these two services. Payments are to be made out to Siena Fertility + Wellness.
You have chosen from one of two payment options
___ One time payment of $775.
___6 Month Payment Plan. The total amount is split into 6 payments of $130. A total of $780.
There are no refunds offered with the available payment options.
*If proof of financial hardship can be provided, adjustments to the fees can be made at the discretion of the practitioner and Siena Fertility + Wellness
For Nutritional Therapy:
I have chosen to learn receive Nutritional Therapy Services from Liz Madsen, FNTP, FCP. I understand that Nutritional therapy is designed to improve my health, but is not designed to treat any specific disease or medical condition. I understand that a Functional Nutritional Therapist is not trained to provide medical diagnoses, and no comment or recommendation should be construed as being a medical diagnosis. I understand that the success of this program depends on my effort in completing the modules in this program. I do not assume that participation in this program will guarantee any specific result.
I understand that if I suffer from a medical or pathological condition, I need to consult with an appropriate healthcare provider. It is important that you contact your other healthcare providers and alert them to your use of nutritional supplements. Nutritional therapy may be a beneficial adjunct to more traditional care, and it may also alter your need for medication, so it is important you always keep your physician informed of changes in your nutritional program. I understand that if I am using medications of any kind, I’m required to alert the Functional Nutritional Therapist to such use, as well as to discuss any potential interactions between medications and nutritional products with my pharmacist. Every client is an individual, and it is not possible to determine in advance how your body will react to the supplements you need. It is sometimes necessary to adjust your program as we proceed until your body can begin to properly accept products geared to correct the imbalance.
The cost for Nutritional Therapy is $400 for the Initial Nutrition Consultation which is 2 hours long. Each additional 1 hour follow-up cost $150 and a personalized Wellness Plan is $100. Your practitioner can provide you with a receipt with codes for you to submit to your medical insurance, however we cannot guarantee that your plan will cover our service. Health savings account funds can be used for this service usually without any trouble.
Payments are to be made out to Siena Fertility + Wellness.
___ One time payment of $800.
___6 Month Payment Plan. The total amount is split into 6 payments of $135. A total of $810.
*A Nutritional Therapist is not licensed or certified by any state. However, a Functional Nutritional Therapy Practitioner™ is trained by the Nutritional Therapy Association, Inc.® which provides a certificate of completion to students who have successfully met all course requirements, including a written and practical exam.
For Feed Your Fertile Body™:
I have chosen to learn about the Feed Your Fertile Body™ Program (FYFB). I understand that attendance at all follow-ups is helpful for the success of the program. I understand that the success of this program depends on my effort in completing the modules in this program. I do not assume that participation in this program will guarantee pregnancy. The cost for teaching this system is $400 which includes 6 Module meetings which are each $60 and the Materials which are $40 plus tax. This fee does not include the cost of shipping. This fee can be paid by several methods outlined below. Your practitioner will provide you with a receipt with codes for you to submit to your medical insurance, however we cannot guarantee that your plan will cover our service. Health saving account funds can be used for this service usually without any trouble. Please select the method of payment you intend to use.
Payments are to be made out to Siena Fertility + Wellness. You have selected of the following payment methods:
_____1 Payment. The entire program is paid for in one lump sum of $400 plus tax on materials.
_____5 Month Payment Plan. The total amount is split into five payments of $80 plus tax on materials billed for five months until the total of $400 plus tax on materials is fulfilled.
Once you have selected your payment method and received your materials, if you choose to discontinue use of the program we request notice to your practitioner of your withdrawal from use. A final bill will be assessed at that time if there are any outstanding payments to date. There are no refunds offered with the available payment options.
