Good to Great Family Wellness Center (hereinafter "G2G" or "the Practice") is an integrative, patient-centered wellness practice operating under the clinical leadership of Kenley Pierre-Louis, APRN, FNP-BC, a board-certified Family Nurse Practitioner licensed in the State of Florida. G2G provides services across the following divisions: Medical Aesthetics & Regenerative Medicine, Medical Weight Loss & Peptide Therapy, Post-Surgical Recovery & Therapeutic Bodywork, Geriatric Life Coaching & Concierge Wellness Support, Youth Athletic Performance Optimization, and Natural Therapeutic Wellness.
The services offered at G2G are provided within the scope of an Advanced Practice Registered Nurse (APRN) functioning under a Florida-issued license and, where applicable, a collaborative or supervisory agreement with a licensed Florida physician. G2G is not a hospital, urgent care center, or primary care medical practice and does not provide emergency medical services. Patients requiring emergency care should call 9-1-1 or proceed to the nearest emergency department immediately.
Many services offered by G2G are elective, aesthetic, or integrative wellness services. These services are not intended to diagnose, treat, cure, or prevent any disease unless explicitly stated in a provider-signed treatment plan. The patient acknowledges that participation in G2G programs is voluntary and elective in nature.
By signing this document, I voluntarily consent to the evaluation, consultation, and treatment services provided by G2G and its clinical staff. I acknowledge that I have been given the opportunity to ask questions and that those questions have been answered to my satisfaction prior to signing.
I understand that I have the right to refuse or withdraw consent for any treatment at any time without penalty, except for services already rendered for which payment remains due. Withdrawal of consent must be communicated directly to a G2G staff member and documented in my clinical record.
I acknowledge that I have been informed of the nature of my proposed treatment, the material risks and potential benefits, and any reasonable alternatives. I understand that no guarantee of results has been made and that individual outcomes vary.
I consent to modifications in my treatment plan as deemed clinically appropriate by my provider, and understand that such modifications will be discussed with me prior to implementation to the extent reasonably practicable.
I understand that neuromodulator and dermal filler treatments are minimally invasive aesthetic procedures. I have been informed of the following risks, which include but are not limited to:
I confirm that I have disclosed all relevant medical history, current medications, supplements, and known allergies. I understand that withholding material health information releases the clinician from liability for adverse outcomes attributable to such omission.
I understand that medical weight loss therapies including GLP-1 receptor agonists (e.g., Semaglutide, Retatrutide) and peptide-based protocols (e.g., BPC-157, CJC-1295/Ipamorelin, Tesamorelin, PT-141) may include the following risks:
Non-FDA Approved Therapy Acknowledgment: I specifically acknowledge and accept that certain peptides and compounded medications prescribed at G2G are not FDA-approved for my specific indication. My provider has discussed the rationale, available evidence, and alternatives. I consent to proceed with full understanding of this status.
I understand that post-surgical recovery services including MLD, scar mobilization, and therapeutic bodywork are designed to support healing and do not constitute surgical care. Risks may include:
I understand that the G2G Geriatric Life Coaching & Concierge Wellness program is a supportive, non-emergent wellness coaching service. I acknowledge the following:
For patients under the age of 18, this consent must be signed by a parent or legal guardian. We understand that the Youth Athletic Performance Program includes laboratory diagnostics, nutrition programming, and supervised fitness guidance. Risks may include:
I consent to receiving healthcare services via telehealth technology. I understand:
G2G operates on a cash-pay, fee-for-service, and membership subscription model. Payment is due in full at the time of service unless a payment arrangement has been pre-authorized in writing. G2G does not bill insurance carriers for services rendered. Patients are responsible for seeking their own insurance reimbursement if applicable.
Monthly membership subscriptions are billed on a recurring basis on the enrollment anniversary date. Memberships may be paused or cancelled with a minimum of 30 days' written notice prior to the next billing cycle. Refunds will not be issued for partial membership months already billed.
Appointments cancelled with fewer than 24 hours' notice or missed without notice are subject to a cancellation fee of up to $75.00 or the full cost of the reserved service, whichever is less. Repeated no-shows may result in discharge from the practice.
Returned checks or failed electronic payments are subject to a $35.00 processing fee. Accounts delinquent beyond 60 days may be referred to a collections agency. Patient agrees to reimburse G2G for all reasonable collection costs including attorneys' fees.
I understand and acknowledge that all medical, aesthetic, and wellness services carry inherent risks including adverse reactions, complications, unsatisfactory outcomes, and in rare circumstances, serious injury. By voluntarily electing to receive services at G2G, I knowingly and voluntarily assume all such risks.
To the fullest extent permitted by Florida law, I hereby release, discharge, and hold harmless Good to Great Family Wellness Center, its owner(s), clinicians, employees, contractors, affiliates, and agents (collectively, “Released Parties”) from any and all claims, demands, losses, damages, or causes of action arising from or related to services received at G2G, except in cases of gross negligence or willful misconduct as defined under Florida law.
No promise, warranty, or guarantee of specific results has been made to me by any G2G clinician or staff member. Clinical outcomes vary based on individual patient factors including genetics, adherence to post-treatment instructions, lifestyle factors, and comorbid conditions. Dissatisfaction with aesthetic or wellness outcomes alone does not constitute grounds for a refund or legal claim.
I bear full responsibility for the accuracy and completeness of all health information I provide to G2G. Any adverse outcomes resulting from my omission, misrepresentation, or failure to disclose material health information — including current medications, supplements, prior procedures, allergies, or diagnosed conditions — shall not be attributed to the liability of G2G or its clinicians.
In the event that a claim is found valid and not barred by this Agreement, the liability of the Released Parties shall be limited to the total amount paid by the patient for the specific service giving rise to the claim, not to exceed a twelve (12) month period of payments. Released Parties shall not be liable for incidental, consequential, indirect, punitive, or special damages.
I agree to indemnify and hold harmless the Released Parties from any claims, damages, or expenses, including reasonable attorneys' fees, arising from my breach of this Agreement, my provision of inaccurate health information, or my failure to follow clinical instructions.
I acknowledge that I have been offered a copy of G2G’s Notice of Privacy Practices (NPP), which describes how my protected health information (PHI) may be used and disclosed in accordance with HIPAA and applicable Florida statutes.
I authorize G2G to contact me via phone, text message, and email for appointment scheduling, clinical follow-up, prescription management, and billing communications. I may opt out of non-essential communications at any time.
I authorize G2G to take clinical photographs or other documentation of treatment areas for clinical recordkeeping purposes only. Such images will NOT be used for marketing or promotional purposes without my separate written authorization.
If the patient is a minor (under age 18) or is otherwise unable to provide consent, the signing party warrants that they are the parent or legal guardian with full authority to execute this consent on behalf of the patient.
In the event of any concern or dissatisfaction with services at G2G, I agree to contact G2G directly and in good faith prior to initiating any public complaint, online review, or social media posting. G2G is committed to resolving all concerns professionally.
I agree not to make any false, misleading, or defamatory statements about G2G, its clinicians, staff, or services on any public platform including Google, Yelp, Facebook, Instagram, TikTok, or any other social or review platform. False or defamatory statements may subject me to legal action under Florida defamation and trade libel statutes.
The G2G brand, logo, name, treatment protocols, pricing structures, and marketing materials are proprietary. I agree not to reproduce, distribute, or misappropriate any G2G intellectual property without prior written consent.
This Agreement shall be governed by and construed in accordance with the laws of the State of Florida. Venue for any legal proceedings shall be in the county in which G2G’s principal place of business is located.
Prior to initiating any legal action, I agree to participate in good-faith mediation with a mutually agreed-upon mediator. The cost of mediation shall be shared equally unless otherwise agreed in writing.
If mediation does not resolve the dispute, I agree that any remaining claims shall be submitted to binding arbitration per the rules of the American Arbitration Association (AAA). I understand that by agreeing to arbitration, I am waiving my right to a jury trial. The arbitrator’s decision shall be final and binding.
I agree that any dispute shall be resolved on an individual basis only. I waive any right to participate in a class action lawsuit or class-wide arbitration against G2G or its Released Parties.
Please initial each line below to confirm your understanding. This checklist is a required component of your consent and must be completed in full.
By signing below, I represent and warrant that: (1) I am the patient or the patient's authorized legal representative; (2) I am at least 18 years of age or am a legally emancipated minor; (3) I have read this entire document, including all sections and disclosures; (4) I fully understand its contents; and (5) I agree to be bound by all terms set forth herein. This consent is binding upon signing and shall remain in effect for all subsequent visits unless revoked in writing.
