Welcome To Wellness & Weight Loss At Berkeley Naturopathic Medical Group!

Welcome to Wellness & Weight Loss at Berkeley Naturopathic Medical Group! We are happy that you have chosen to pursue our Wellness & Weight Loss program at Berkeley Naturopathic Medical Group. Our goal is to provide you with the highest quality wellness education possible. We are committed to a healthy and honest relationship from the start and for this reason we ask that you take the time to review our program and payment policies. Please sign below to acknowledge that you have read and understand these policies. PROGRAM STRUCTURE: SMALL GROUP FORMAT Structure: Groups of 3-6 participants, 8 lectures (75 min each), once a week (some variation) Schedule: Saturday morning lectures at BNMG Group A: 9:30a – 10:45a Group B: 11:00a – 12:15p Group C: 12:45p – 2:00p Fees: One payment . 949 Three payments . . 339 each Blood work is not included in price of program. See separate document on blood work. LARGE GROUP FORMAT Structure: Groups of 15-25 participants, 8 lectures (75 min each), once a week (some variation) Schedule: Evening lectures at Energy Matters Acupuncture & Qigong (4341 Piedmont Ave Suite 202 Oakland, CA) Group D: Mondays 7:00p – 8:15p (some lectures start at 7:15p) Group E: Thursdays 5:30p – 6:45p Fees: One payment . 649 Three payments . . 239 each Blood work is not included in price of program. See separate document on blood work. ONE-ON-ONE FORMAT Structure: Individual and customized discussion of wellness and weight loss goals with structured education at each visit mirroring the group program Call for more info 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 888.972.7331 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com

PROGRAM POLICIES: Cancellation Policy: At Berkeley Naturopathic Medical Group, we respect your time, and we trust that you respect ours. For group programs we require a minimum of 8 business days notice* when canceling registration. For one-on-one programs, when canceling or rescheduling appointments, we require a minimum of 3 business days notice* for initial appointments and 2 business days notice* for follow-up appointments. Once registered, whether you choose to pay in full or opt for a payment plan option, if you choose to cancel your enrollment you will be charged the following fees dependent on when you submit your cancelation request: If you cancel before the required cancelation date (as indicated above), you will be charged a 50 cancelation fee. If you cancel after the required cancelation date, you will be charged 50% of the remaining cost of the program. Please understand that this policy is in place as a means of respecting the time and efforts of your doctor/educator and the office staff, as well as others who would have benefited from participation in this program. Should we have to change appointments, we will do our best to give you 2 business days notice and will be sure to accommodate your needs and reschedule your appointment in a timely fashion. *By 5pm on that business day Lecture recordings: Each lecture is recorded in the case of participant absence. If you have a planned or unplanned absence you will be provided with the video recording. A YouTube account is necessary to gain access to the recording so please set one up if you do not already have one. It is important to watch the recording as soon as possible following your absence in order to stay on top of the material and assignments. Confidentiality agreement: The information contained in this program is fundamental and foundational and should be shared with others to improve the health of our communities. Please feel free to verbally share the information you learn in the course and feel free to share copies of the dietary handouts you receive with people you know and care about. Please, however, refrain from sharing the slides from the powerpoint presentations or any recorded material you take or receive during the program. Scent-Free Policy: Our office is a fragrance-free zone. Please refrain from wearing perfume, cologne, and other scented products when visiting us, in order to support the health of our chemically sensitive clients. 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 888.972.7331 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com

Phone Consultations: If you are unable to come to our office for your on-on-one program, follow-up visits via telephone are available after an initial in-person visit. These are billed at the regular in-office rate and payment is due via credit card at the end of each call. Email Consultations: Wellness & Weight Loss programs are not offered via email at this time. Supplements: Supplements are not required as a part of the Wellness & Weight Loss program. Should you choose to purchase any supplements through our office, all sales on supplements and botanicals are final. Please note that the purpose of selling supplements to patients is to make available the most effective and highest quality products that are often only available for sale through licensed professionals. It may happen that you need a refill prior to your next appointment. Please call or email with your refill request 5 business days before you are scheduled to finish your supplements. Supplement orders requested less than 5 business days in advance will be accommodated as soon as possible but may not be immediate due to available time and stock. All refills must be paid for at the time they are dispensed and can be picked up at the office or mailed to your home. If you need to pick up supplements after hours, supplements are left out at your own risk. Insurance & Payment: Your health insurance policy is a contract between you and your insurance company and you are responsible to know your coverage. Many private insurance companies have policies that do cover some or part of the one-on-one care you receive from Berkeley Naturopathic Medical Group. Whether your particular policy is one that has such coverage is a detail you can learn from your insurance agent as our office does not have access to that information. Group programs are not covered through insurance though may be covered by an HSA or FSA. All charges incurred at our office are your responsibility regardless of insurance coverage. Payment in full is due at the time of service. This includes fees for medical office visits, labs and any herbal/nutritional supplements prescribed for you. For your convenience we accept cash, check, Visa, and MasterCard. At the end of each one-on-one visit, you will be provided with a superbill that you can use to submit to your insurance for possible reimbursement. The Berkeley Naturopathic Medical Group does not bill insurance and currently, federal programs such as Medicare and Medicaid do not reimburse for naturopathic medical services. Bounced checks incur a 25 processing fee. Refunds on labs are available with a 25 processing fee, provided the labs were not performed, the kits were not tampered with and are returned in a reusable state and that no more than 10 months have passed since their issue. There are no refunds on services. 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 888.972.7331 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com

I understand and agree to the program and payment polices listed above, including: Program structure Program policies: o Cancellation policy o Lecture recordings o Confidentiality agreement o Scent-free policy o Phone consultations o Email consultations o Supplements o Insurance & Payment Print Name Signature Date 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 888.972.7331 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com

BLOOD WORK Blood work is an important part of understanding your own unique biochemistry and a helpful way of tracking progress. The following panel of blood work is designed to help us optimize your health as well as screen for some common issues that people experience. This panel may be slightly different than what you might get with your MD because we are looking at it with an eye for prevention. This means we are testing things that conventionally wouldn’t be tested until a specific disease is diagnosed. Blood work is reviewed during week two of the group program and during an initial appointment in the one-on-one program and must be current (within 2 months of the start of the program, please call to discuss if you have had these labs done in the last 6 months). The following fasting blood work is required: o Complete Blood Count with differential o Ferritin o Comprehensive Metabolic Panel 14 o Hemoglobin A1c o Insulin o NMR (a special lipid panel) o Thyroid panel (TSH, free T3, free T4, reverse T3) o Vitamin D, 25-OH o ESR or CRP There are three options for getting your blood work done: o You request that your Primary Care Provider (PCP) order them: Your MD/ND/DO/PA/NP may be willing to order some or all of the necessary blood work. Request that results are copied to Dr Tara Stoop and also directly to you. Bring the results to your initial appointment for the one-on-one program or to the first week of the group program. o You pay for them out of pocket: This is payable to Berkeley Naturopathic Medical Group and the results are released directly to us. Call Berkeley Naturopathic to request a requisition. a. Full panel: 289 b. Full panel with standard lipid panel instead of NMR: 239 c. Limited panel (does not include NMR or thyroid screen): 158 d. Blood sugar panel (only includes fasting glucose, insulin & hemoglobin A1c): 65 o A combination of options #1 and #2: if your PCP is willing to run some but not all of the listed labs, the remaining labs can be paid for out of pocket. It is important that the thyroid panel is run from the same blood draw so it is necessary for your MD to run the entire panel and if not, the entire panel must be done out of pocket. Call Berkeley Naturopathic to request a requisition. Please get your blood drawn after a 10-12 hour fast. No food is allowed but plenty of water is encouraged. Please allow 10 business days for the results to come back so plan to get your blood drawn with adequate time before the start of your program. If you are currently on thyroid medication, please also get the blood drawn 2-4 hrs after taking your morning dose. This allows us to see what your thyroid hormone levels are when the medication is at its peak in the blood. 2615 Ashby Ave Berkeley, CA 94705 P: 510.845.8600 F: 888.972.7331 officemanager@berkeleynaturopathic.com www.berkeleynaturopathic.com