Fireweed Functional Medicine
Fee-for-Service Agreement
Date: April 17, 2026

This agreement outlines the terms of care under the Fee-for-Service model.

1. Nature of Services

Fireweed Functional Medicine provides specialty functional medicine services. This practice does not provide primary care, urgent care, or emergency services.

You are responsible for maintaining a relationship with a primary care provider.

2. Fees

  • Initial Consultation: $625

  • Follow-Up Visit: $515

Payment is due at the time of scheduling your visit.

3. What Is Included

Fee-for-service visits include:

  • Scheduled in-office or telehealth visit

  • Review of relevant labs prior to visit

  • Updated treatment recommendations

  • Documentation and care plan

4. What Is NOT Included

Fee-for-service care does NOT include:

  • Unlimited messaging, texting, or portal support

  • Ongoing treatment adjustments outside of scheduled visits

  • Management of new conditions without an appointment

  • After-hours communication

  • Primary, urgent, or emergency care

Extended communication, care coordination, or clinical management outside a scheduled visit may require:

  • Scheduling a follow-up visit, or

  • Enrollment in the Membership Program

5. Communication Boundaries

Brief administrative messages are permitted.

Clinical questions, treatment changes, new symptoms, lab interpretation, or ongoing back-and-forth communication require a scheduled visit.

If care needs become ongoing or frequent, you may be advised to enroll in the Membership Program for continued support.

6. Prescription Refills

Prescription refills may be provided for up to 12 months from the date of your last visit, at the provider’s discretion, for stable conditions.

Refills do not include:

  • New medications

  • Dose changes

  • Management of new symptoms

  • Medications requiring reassessment

These require a scheduled visit.

7. Transition to Membership

If your care requires regular adjustments, messaging, or frequent interaction over a 3–4 month period, you may be advised to transition to the Membership Program for continued access and support.

8. Acknowledgment

By signing below, you acknowledge that you understand:

  • This is specialty functional medicine care

  • This practice is not your PCP

  • Messaging and ongoing access are not included

  • Clinical care requires scheduled visits

Patient Name: ___________________________

Signature: ______________________________

Date: _________________________________