Consent Form

Priority Breakthrough

Please open and read each of the following statements and terms before acknowledging acceptance at bottom of the page.  

Each of the respective professionals at Donielle Wilson, N.D., Inc. d/b/a Dr. Doni (“Dr. Doni” and its professionals “the Dr. Doni Professionals”) is a Naturopathic Doctor who has been awarded a doctorate in Naturopathic Medicine and has completed their residency in Naturopathic Medicine. Optionally each of the respective Dr. Doni Professionals may have a certificate in Midwifery, and may have completed internships in both midwifery and women’s health.

Each of the respective Dr. Doni Professionals is licensed as a Naturopathic Physician in Connecticut, Arizona, California, and/or Washington states, or all of the above. Optionally, each of the respective Dr. Doni Professionals may also be certified as a midwife by the North American Registry of Midwives (NARM) and the Certification Board for Nutrition Specialists.

Each of the respective Dr. Doni Professionals is NOT a medical doctor. They are NOT licensed as a midwife and do not provide prenatal care and do NOT care for patients during labor.

Each of the respective Dr. Doni Professionals does not write or change prescriptions and does not do any screening exams in NY. It is important that you are under the care of a medical practitioner and that you follow the recommendations of that practitioner.
Patients who are pregnant must be under the care of an obstetrician or midwife who does provide prenatal care and must plan all emergency transport care with that practitioner. Patients who have a current diagnosis of cancer MUST be under the care of an oncologist.

In New York (and any other locations where a license is not offered), each of the respective Dr. Doni Professionals provides their services as a consultant because New York State does not license the profession of naturopathic medicine.

We are a private member association. Services may include dietary and lifestyle recommendations, suggestions regarding the use of natural therapies, and support with wellness care.

Dr. Doni’s method of healing requires each of the Dr. Doni Professionals to look at the body as an intricate, whole system; a problem with one part of your body will be considered within the context of your entire being. When coming up with a plan for improvement of health, each of the respective Dr. Doni Professionals will focus on any or all of the following: your digestive health and diet, your sleep patterns, your neurological health, mood, amount of stress, and your menstrual cycle. Each of the respective Dr. Doni Professionals will help to restore these areas of health through natural therapies to establish healthier balances within the body.

A consultation with each of the respective Dr. Doni Professionals does not create a doctor-patient relationship.

You also agree not to rely on information provided by any of the respective Dr. Doni Professionals as a substitute for, nor a replacement of, professional medical advice, diagnosis, or treatment. If you have any concerns or questions about your health, you should always consult with a physician or other healthcare professional. Do not disregard, avoid or delay obtaining medical or health-related advice from your healthcare professional because of your interaction with any of each of the respective Dr. Doni Professionals. The use of any information provided by any of each of the respective Dr. Doni Professionals is solely at your own risk.

Nothing stated or made available through any services provided by any of each of the respective Dr. Doni Professionals are intended to be, and must not be taken to be, the practice of medicine or the provision of health care treatment, instructions, diagnosis, prognosis, or advice.

You understand that suggestions provided may be considered “experimental” and not standard of care. When those services are provided, you agree that you are accepting responsibility for your health and any risk associated.

By consenting to services provided by Dr. Doni, you consent to physical contact and to the willingness to experience changes in your health.

You consent to taking responsibility for following any recommendations provided.

There are no guarantees of improvement in your health. The best outcomes occur with consistent follow-up appointments, when we work together to create your plan, and when you take responsibility for your health and healing.

In the interest of your safety and effective care, all case updates are handled through phone or office appointments only (not email or non-appointment calls). There are no exceptions to this policy.

You may text or email with simple questions. More complex questions and follow-up on recommendations require a paid appointment.

If you experience any unexpected or negative symptoms you understand to discontinue any supplements and/or recommendations and to contact your doctor and Dr. Doni for an appointment or, if an emergency, to seek emergency care. 

Follow-up appointments/consultations are billed separately from the initial consultation and separate from tests. When you purchase a “package” or program that includes more than one consultation, we will apply the time used during consultations to the total time of the paid package and inform you when the time has been used.
Test fees do not include a consultation. Results are reviewed during a paid appointment. Other than IgG/IgA food panels, tests are only available to current patients or participants in paid group programs.

We are not able to refund fees for consultations, packages of consultations, tests, or services.

If over 2 years have passed since your last appointment with any of each of the respective Dr. Doni Professionals, we may require that you complete an initial appointment again or pay a “reactivation” fee.

Continued refills on products may require follow-up appointments and tests before being refilled.

We are not able to submit forms to insurance companies on your behalf.
Products are billed at retail prices, with the addition of shipping fees when shipped. Unopened products may be returned within one month of purchase, as long as they did not require refrigeration.
To facilitate billing, we ask that you keep a credit card on file with us. We need to have your credit card information on file before appointments by phone. By signing this consent, you consent to the use of your credit card for outstanding balances. If at any point you need to change or remove your card from our records, you must contact us with that request.
Your records are confidential. If you would like to share your information with a person assisting with your care (and you are over 18 years old) or with another provider, it is required that you sign a medical release form.

If you ever have any concerns regarding our work together, you agree to contact Dr. Doni to discuss those concerns so that we can resolve any miscommunications together. Any disputes will be handled by arbitration with the American Arbitration Association in New York.

By typing my full name in the box below I acknowledge and accept the terms and conditions. I understand that these terms apply to working with Dr. Doni and any representatives thereof.