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Survive to Thrive Program

6 Month Program

Using the AMOUR SYSTEM

Comprehensive Initial Naturopathic Consultation ✔︎
Specialty Labs Ordered to Look at Food Sensitivities, Vitamin/Mineral Deficiencies, Adrenal Function, Hormones, and Neurotransmitters ✔︎
Follow-Up Consult to Review Labs ✔︎
(2) 45-Minute Telemedicine Flex Appointments EVERY month to keep you engaged, motivated and on track with your health progress. ✔︎
6 Online Workshops with Dr. Alice ✔︎
6 Month FREE Access to All Upcoming Online Workshops ✔︎
Final Follow Up Consult ✔︎
Exclusive Facebook Group ✔︎
Discount On All Supplements ✔︎
Nutrition Handouts ✔︎

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Date of Birth (MM/DD/YY) *

Terms of Acceptance *

1. I agree to answer all questions pertaining to medical conditions truthfully and consent to receive wellness consulting from Amour de Soi Wellness. I understand that all information is held in strict confidentiality to the full extent of the law. I understand it is very important that the client builds a strong sense of trust with the practitioner and if there is anything further I would like to discuss with Dr. Alice Fong before or during the program or any boundaries that I would like set to ensure my comfort, I agree to bring these issues to her attention.
2. I understand that licensed naturopathic doctors (NDs) are trained as primary care physicians but the scope of practice varies state by state, and usually limited to prevention, diagnosis, and treatment of human health conditions, injury, and disease using naturopathic therapies such as counseling, hydrotherapy, nutrition, phytotherapy, natural substances, and external applications. A licensed naturopathic doctor (ND) can order labs. However, a licensed ND CANNOT (in most states) prescribe, dispense, or administer any prescription drugs, perform surgical procedures, administer ionizing radioactive substances, or perform acupuncture.
3. I understand that Dr. Alice Fong will NOT be acting as my Primary Care Physician but as a Specialist in managing my stress and anxiety and/or as a Wellness Consultant to optimize my health and wellbeing. I understand that Dr. Alice Fong does NOT accept insurance, and agree to pay the full 6-month ‘Survive to Thrive Program’ fee.
4. I agree to enter this 6-Month ‘Survive to Thrive Program’ to improve my health and wellbeing. I agree to automatic monthly payments of $449/month for 6 months or a 1 time payment of $2600. If I need to terminate the contract early for whatever reason, I agree to pay a $600 early cancellation fee. If my card is declined for any of the automatic payments, I agree to pay a $100 fee, in addition to the monthly payment.
5. I agree to participate in TWO 45-minute telemedicine consultations a month and will do my best to have both consults in the same month. I understand I can roll over up to 1 of my 2 consults into the following month if necessary, but no more than 1 (example: If I take a trip and can only have 1 consult in January, I can roll over the 2nd consult to the next month and have 3 consults in February, but I cannot have both my January consults in February which would result in 4 consults in a month. I understand if I miss a consult in January, it can be rolled over into February but not March or beyond).
6. I agree to provide at least 48 hours notice if I need to reschedule any of my scheduled appointments, but will notify Amour de Soi Wellness as soon as I know an appointment needs to be rescheduled. I understand that there’s an impact on Dr. Alice’s schedule to cancel or reschedule with little notice, because that is a time slot that could have been utilized by another client. If I need to cancel or reschedule with less than 48 hours notice, I agree to pay a $50 cancel/reschedule fee for each occurence. If I DO NOT show up for my appointment or give notice after the start time of the appointment, I understand I will lose that session completely OR have to pay a $200 no show fee to reschedule that session.
7. I understand that if necessary, Dr. Alice Fong will refer me to and consult with physicians and other licensed health care providers. In cases where I am diagnosed with a life threatening condition, Dr. Alice Fong will counsel and discuss with me the potential benefits offered by other physicians or other healthcare professionals and will attempt to make the appropriate referral.
8. I understand that Dr. Alice Fong has the right to refuse treatment or terminate my participation in the program for any reason. Rarely would she ever do so, but some possible reasons could include disrespect, inappropriate behavior, harassment and frequent no show or late cancelation to appointments. If she chooses to do so, any remaining payments will be discussed.

I understand that checking this box constitutes I have read all of the above terms and is a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.

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