Patient Agreement

INTRODUCTION

This Agreement is entered into by and between Ikigai Family Physician (“practice”), a State of New Mexico LLC, Kristy Riniker, MD (practitioner) and the undersigned patient (“member”). Ikigai Family Physician is a Direct Primary Care medical practice. The practitioner of Ikigai Family Physician offers primary care and many urgent care services to the members of Ikigai Family Physician. The practitioner delivers care on behalf of Ikigai Family Physician at 200 Valle Alto Dr NE, Rio Rancho, NM 87124, and also provides care via electronic communication and phone, and provides visits to members’ homes. In exchange for the fees set out in this Agreement, the practitioner and practice agree to provide the member the services set forth below. This agreement is entered by mutual voluntary consent.

SERVICES

Member understands that practitioner will provide a limited set of services which are generally within the scope of the practice of primary care. Member acknowledges that practitioner’s ability to provide care may be limited by training, experience, equipment and supplies and other unforeseen circumstances.

INCLUDED SERVICES. In exchange for the monthly fee described below, Members shall receive the following services:

In-person Office Visits. If you choose to be seen in our office, we will generally have a same-day appointment available for you. We will always schedule sufficient time to thoroughly discuss your healthcare.
Virtual Care. Your time is valuable, and so you may choose to receive your care virtually via video visit, telephone or text. We consider Virtual Care a vital part of your membership and we are swift to respond to your needs.
Out of Office Visits. Occasionally, it may be most appropriate for you to receive care at your home or office. We will provide out of office visits as our schedule allows, subject to certain limitations. Home visits within the service area of the communities of Rio Rancho, Corrales, Bernalillo, and Albuquerque are included. The boundaries of the service area are 550 to the north, 423 to the south, the Rio Grande to the east, Unser to the West. Home visits outside of these areas will be charged travel time at a rate of $100/hour.
Annual Physical Exam. Your health and longevity are best served by periodic oversight. Therefore, we will perform a comprehensive annual physical examination to monitor existing health conditions and recommend preventative treatments.
Participation Physical Exam. Often a physical exam is needed for work, school, sports or camps. This is included as part of your membership and we can provide you with standard forms or fill out whatever forms are needed by your organization.
Urgent Care. When you do not feel well, we can evaluate you in-person or virtually at home or the location of your choosing.
Lifestyle Medicine Program. Your good health is about more than avoidance or management of illness; it is about developing optimal performance for your lifestyle. Our Lifestyle Medicine Program is included in your membership and includes an individualized program focused on the 6 pillars of lifestyle medicine - nutrition, physical activity, restorative sleep, stress management, social connection and avoidance of risky substances.
Travel Medicine Consultation. We recommend pretravel consultation 6 weeks before traveling outside the country and will perform risk assessment, advise on vaccines, preventive care planning and contingency care planning.
In-Office Ancillary Diagnostic Services. Your care may require in-office ancillary services such as point of care ultrasound, electrocardiography, peak flow monitoring. Most ancillary services are included in your membership, but some may have an additional fee. These will be communicated to you upfront.
In-Office Ancillary Treatment Services. Your care may require in-office ancillary services such as incision and drainage, skin and soft tissue excisional biopsy, long acting reversible contraceptive placement and removal, joint injection, trigger point injection. Most ancillary services are included in your membership, but some may have an additional fee. These will be communicated to you upfront.
Specialty Care Coordination. If your care requires the services of medical specialists outside of our office, we will make every effort to source the appropriate referral for you and process the referral expediently. Once the specialist consultation is complete, we will continue to work with your specialists to coordinate care with our office. While hospitalist services are not a part of your membership, if you are admitted to the hospital, we will work diligently with your hospital practitioners to facilitate the best care available.
After hours direct communication with Physician via practitioner’s cell phone through voice calls, text messaging, and email access and patient portal and during practice hours when practitioner is not providing service to other patients.
All services, tests and procedures shall be performed when reasonable and necessary at the practitioner’s sole discretion. Additional fees may apply for other goods and services, but every effort is made to keep those fees to a minimum.

EXCLUDED SERVICES. The following non-exhaustive list of services are not covered in the Membership Fee:

Medical imaging such as X-rays, mammograms, CT scans, full diagnostic ultrasounds, elastography MRI, etc.
Labs and other tests
Any surgery or procedure not performed in this office (e.g. in a hospital, or another physician’s office)
Immunizations
Injectable medications
Obstetrical care and delivery
Durable medical equipment and supplies (e.g. crutches, wheelchairs, walking boots, casts, etc)
Prescription medications:
In office dispensing of prescription medications (for purchase) is not currently available. Prescriptions will be sent to the member’s preferred pharmacy.
Physician does not provide opioids for chronic pain management or benzodiazepines for chronic anxiety
Member shall be entitled to some of the above non-covered services at a reduced fee (e.g discounted labs).

INFORMED CONSENT TO TREAT
I hereby give my consent for Ikigai Family Physician to provide comprehensive medical treatment.
I understand and I am informed that, as with all healthcare treatments, results are not guaranteed and there is no promise of cure.
I have had the opportunity to discuss with my practitioner the nature and purpose of treatments and procedures. I am aware that all existing methods of diagnosis and treatment pose some level of risk.
I do not expect the practitioner to be able to anticipate and explain all risks and complications, and I wish to rely on the practitioner to exercise judgment during the course of the treatment which the practitioner feels at the time, based upon the facts then known, is in my best interests.
I will immediately inform the practitioner if I experience any unanticipated or unpleasant effects associated with treatments prescribed/recommended. I understand that if an emergency medical condition arises, I am expected to call 911

TELEHEALTH CONSENT
I consent to voluntarily engaging in a telemedicine consultation with the practice. I understand that the video conferencing technology will not be the same as a direct patient/health care practitioner visit.
Telehealth consultation has potential benefits, including easier access to care, decreasing costs, and allowing visits to be performed from the comfort of my home. It also has potential risks including interruptions, unauthorized access, and technical difficulties.
I understand that my health care practitioner or I can discontinue the telehealth consult/visit if it is felt that the videoconferencing connections are not adequate for the situation.
If there is another individual present during the telehealth consultation, I will be informed of their presence and I will also disclose if there is another individual with myself. It is agreed that these individuals will maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non-medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
I understand that telemedicine has limitations in regard to the physical examination. I understand that the physical exam portion of the care provided through the practice will be limited to inspection via video conferencing and some parts of the exam such as physical tests, examination of certain body parts, and vital signs may be conducted by individuals at my location at the direction of the consulting health care practitioner or not done at all.
Telemedicine services offered through the practice are not an Emergency Service and in the event of an emergency or urgent medical issue, I will use a phone to call 911, go to the emergency department, or go to an urgent care.
To maintain my privacy, I will not share telemedicine login information or video conferencing links with anyone unauthorized to attend the appointment.

TELEPHONE CONSULTATION CONSENT
I understand that the practitioner / the practice may allow telephone consultations - verbal conversation only / no video. I understand that these consultations have considerable limitations, including but not limited to no physical exam or visual assessment. I understand that my practitioner, during the telephone consultation, may determine that adequate care and treatment will not be possible with the limited assessment via telephone consultation. I agree to follow through with them on any required in-person office visits or video telehealth visits. I consent to receive instructions via phone/telemedicine platform and take full responsibility to follow through with specific instructions as required for my treatment. I have had the opportunity to discuss the limitations with my practitioner.

EMAIL USE CONSENT
The preferred method of communication is via HIPPA-compliant Patient Portal. However, the practitioner / the practice provides patients with the opportunity to communicate by e-mail. Transmitting confidential health information by e-mail, however, has a number of risks: E-mail can be immediately broadcast worldwide and be received by many intended and unintended recipients; recipients can forward e-mail messages to other recipients without the original sender(s) permission or knowledge; users can easily copy information.
It is the policy of the practitioner / practice that all e-mail messages sent or received which concern the diagnosis or treatment of a patient will be a part of the patient’s protected personal health information. The practice cannot guarantee the security and confidentiality of e-mail or internet communication.
Patients may consent to the use of e-mail for confidential medical information after having been informed of the above risks with the following conditions: All e-mails to or from patients concerning diagnosis and/or treatment will be made part of the protected personal health information. As a part of the protected personal health information, other individuals, insurance coordinators and, upon written authorization, other healthcare practitioners and insurers will have access to e-mail messages contained in protected personal health information.
The practitioner / practice will endeavor to read e-mail promptly. However, the practice can provide no assurance that the e-mail will be read immediately. Therefore, e-mail must never be used in a medical emergency.
Because some medical information is so sensitive that unauthorized disclosure can be damaging, e-mail should not be used for communications concerning diagnosis or treatment of any sexually transmittable or communicable diseases such as syphilis, gonorrhea, and the like; behavioral health, mental health; or alcohol and drug abuse.
The practitioner / practice cannot guarantee that electronic communications will be private. The practitioner / practice is not liable for improper disclosure of confidential information not caused by its employee’s gross negligence or wanton misconduct and is not liable for breaches of confidentiality caused by the patient.
I understand that my consent to the use of e-mail may be withdrawn at any time, whether it be by e-mail or written communication to the practitioner / practice. I have read this form carefully and understand the risks and responsibility associated with the use of e-mail. I agree to assume all risks associated with the use of e-mail

TEXT MESSAGING CONSENT
The practitioner / practice may need to use my name, address, phone number, and my clinical records to contact me with appointment reminders/text message, information about treatment alternatives or other health related information that may be of interest to me. If this contact is made by phone and I am not available, a message will be left on my answering machine or with the person answering the phone.
Message and data rates may apply and message frequency may vary. You can contact the practice at any point to request that your mobile number not be used for messaging. You can text HELP for support or more information and STOP to unsubscribe from text messages at any time. If you unsubscribe, you will no longer get appointment reminder messages. Your phone number will not be shared with third parties for marketing or promotional purposes.
By signing this form, I am giving the practice the authorization to contact me with these reminders and information and to leave a message on my answering machine or with individuals at my home or place of employment.
CLINICAL DOCUMENTATION TECHNOLOGY
Ikigai Family Physician uses ambient note-taking technology to enhance clinical documentation and improve the quality of care. This technology securely captures and transcribes portions of the clinical conversation to assist the practitioner in creating accurate medical records. At times practitioner may recommend taking photographs for clinical documentation. These will be loaded into the electronic medical record. Participation is voluntary and you may decline at any time and this will not affect your care or access to services. By signing this agreement you consent to use during clinical visits and understand your rights and how your information is protected.

HOLD HARMLESS
Member agrees not to hold Ikigai Family Physician or our practitioner liable for any loss, injury, damages or expenses beyond Ikigai Family Physician’s or practitioner’s control related to technical failure of the Ikigai Family Physician website, email, or other electronic services, including but not limited to: power outages, faulty cellular, cable, or WiFi service, failure due to internet service practitioner caused by power outages, failure to properly address email messages, interception of communications by a 3rd party, or Member’s failure to follow Ikigai Family Physician’s recommendations regarding electronic communications in this agreement.

OFFICE APPOINTMENTS
The Ikigai Family Physician office is located at 200 Valle Alto Dr NE, Rio Rancho, NM 87124. The office will be open primarily Monday-Thursday from 8:30am-3:30pm. Visits are by appointment only. Online scheduling is available. If there are no open appointments online, a brief phone call or text can secure a timely appointment.

RESPONDING TO MEMBER
Phone calls to Ikigai Family Physician will be answered by Dr. Riniker whenever possible. As she is also providing patient care, she may not be able to immediately answer your call, but she will return your call within 24 hours as long as you leave a message, except in case of emergencies or unavoidable circumstances. If it is urgent, send a text message, or call again. Emails from Member will typically receive a response within 48 hours, though often much sooner. If Member does not receive a response to email within 48 hours, the member should make a phone call or use another means of communication.

ALTERNATE PRACTITIONER
Member understands that the practitioner may be unavailable at times due to patient care, personal illness, injury, emergencies, or other obligations. Ikigai Family Physician will make reasonable attempts to provide alternative coverage in the event of the practitioner’s absence. Should the practitioner anticipate that they will be unavailable for more than 3 consecutive business days, Ikigai Family Physician will send out an email to inform patients of this planned absence. Ikigai Family Physician may use other medical practitioners, nurses, medical assistants and other staff to assist in providing care. All such personnel will be bound by this Membership Agreement.

RELEASE OF INFORMATION
I may restrict the individuals or organizations to which your health care information is released or I may revoke your authorization at any time: however, this revocation must be in writing and mailed to the office address. The practice will not be able to honor my revocation request if they have already released my health information before the request to revoke authorization. In addition, if I was required to give my authorization as a condition of obtaining insurance, the insurance company may have a right to your health information if they decide to contest any of your claims.
Information that the practice may use or disclose based on the authorization I am giving may be subject to re-disclosure by anyone who has access to the reminder or other information and may no longer be protected by the federal privacy rules. I have the right to refuse to give us this authorization. If I do not give authorization, it will not affect the treatment I receive or the methods used to obtain reimbursement for my care.
I may inspect or copy the information that is used to contact me to provide appointment reminders, information about treatment alternatives, or other health information at any time.
This notice is effective on the date of signature. This authorization will expire seven years after the date on which I last receive services from the practice.
I authorize you to use or disclose my health information in the manner described above. I acknowledge that I have received a copy of this authorization.

FINANCIAL POLICIES

INSURANCE OR OTHER MEDICAL COVERAGE

Member acknowledges and understands that this Agreement and the membership described herein is NOT health insurance or a substitute for health insurance. Member recognizes that member may require medical services which Ikigai Family Physician and practitioner cannot provide (e.g. hospitalization, surgeries, specialist consults, etc). Member acknowledges that practitioner recommends (but does not require) that individuals maintain health insurance to mitigate the risks of medical emergencies, injuries and acute and chronic illnesses and diseases.
Member acknowledges that the Program Services provided pursuant to this Agreement are not covered by insurance, Medicare, Medicaid and/or other third-party payor, and neither the Practice nor practitioner participate in any commercial health insurance or HMO plans or panels.
Member understands that Ikigai Family Physician will not bill insurance for services rendered under this Agreement. We can provide you with a superbill with all the necessary codes, so that you may file for reimbursement with your insurance company. Member understands that there is no guarantee that Member will be reimbursed for Ikigai Family Physician’s or our practitioner’s services by any other entity (e.g. private health insurance, a company’s FSA or HSA, etc)
Dr. Riniker does accept assignment for Medicare. The Membership Fee covers the cost of the Program Services, however, Membership Fee does not cover the cost of any health care services covered by Medicare. The Member retains all rights and protections under the Medicare program. This Agreement does not affect the Member’s ability to receive covered services under Medicare or to seek care from other Medicare practitioners. The Membership Fee is not eligible for reimbursement by Medicare and is the sole financial responsibility of the Member. If Member has Medicare, is eligible for Medicare, or during the term of this Agreement becomes eligible for Medicare, the Member will immediately notify the Practice in order to add Medicare coverage to their account.

FEES AND PAYMENTS:

A monthly membership fee is required. At the time of your initial office visit, a credit card will be added to your file. You may pay cash, credit card, HSA card, or Flexible Spending Card.

PER MEMBER MONTHLY FEE BY AGE (effective January 5, 2026)
- 0-20 years $75
- 0-20 years with family member $50
- 21+ years $150
REGISTRATION FEES
- There is an initial $75 registration fee for individual and family enrollment.
- There is a $200 re-enrollment fee if you cancel your membership and then rejoin.
COMMITMENT TO CONTRACTED SERVICES. The member understands that they are signing up for a recurring monthly service contract with Ikigai Family Physician.
CHANGES IN FEES. The membership fee may be changed by Ikigai Family Physician with 90 days prior notice. As always, the Member may cancel at any time if the fee is unacceptable or they are dissatisfied for any reason. Membership fees up until the date of cancellation are nonrefundable.
TERMINATION OF MEMBERSHIP. Ikigai Family Physician requires a 30 day written (may be electronic) notice to terminate membership. This notice should be sent to ikigaifamilydoc@gmail.com.
RETURNED CHECK. There is a $20.00 fee for any check returned by the bank.
PAST DUE ACCOUNTS. Membership is dependent on timely payment of membership fees, and fees 60 days past-due will be cause for termination of membership and services. At the time of your initial office visit, a credit card will be added to your file. If your account becomes past due over 60 days, that credit card will be charged. If the credit card declines or there are any other problems, your account will be referred to our collection agency. You will be charged for this service in addition to your current account balance. If payment is not received, your credit report will be blemished. If we have to refer the collection of the balance to a lawyer, you agree to pay all of the lawyer's fees which we incur, plus all court costs.
CREDIT CARD AUTHORIZATION. I authorize the practice to maintain my credit card number in the electronic health record and to use it to process payment for services rendered or supplements or other items purchased by me. I authorize the practice to process the credit card on file for any balance due on my account past 60 days and for any payments authorized by me. I know that I am responsible for letting the clinic know if anything has changed concerning my credit card information.
COPIES. Your medical records will be available free of charge through the patient portal and can be faxed or emailed to you. The cost for copies of printed lab work, chart notes, imaging, and invoices will be 50 cents per page, except if requested at the time of the visit. Lab work, chart notes, imaging, and invoices pertinent to the visit will be provided free of charge on the day of the visit.

PRIVACY POLICY / HIPPA COMPLIANCE

OUR LEGAL RESPONSIBILITIES

We are required by law to give you this notice. It provides you with how we may use and disclose protected health information about you and describes your rights and our obligations regarding the use and disclosure of that information. We shall maintain the privacy of protected health information and provide you with notice of our legal duties and privacy practices with respect to your protected health information.

We have the right to change these policies at any time. If we change our privacy policies, we will notify you of these changes immediately. This current policy is in effect unless stated otherwise. If the policy is changed, it will apply to all your current and past health information.

You may request a copy of our notice any time. You may contact the practice at 200 Valle Alto Dr NE, Rio Rancho Dr NE or ikigaifamilydoc@gmail.com at any time to request a copy of this privacy policy.

HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION:
The following examples describe ways that we may use your protected health information for your treatment, payments, healthcare operations etc. but please be advised that not every use or disclosure in a particular category will be listed.

Treatment: We may use and disclose your protected health information to provide you treatment. This includes disclosing your protected health information to other medical practitioners, trainees, therapists, medical staff, and office staff that are involved in your health care. For example, your medical practitioner might need to consult with another practitioner to coordinate your care. Also, the office staff may need to use and disclose your protected health information to other individuals outside of our office such as the pharmacy when a prescription is called in.
Payment: Your protected health information may also be used to facilitate payment or reimbursement to you from an insurance company or another third part. This may include providing an insurance company your protected health information for a pre-authorization for a medication we prescribed.
Health Care Operations: We may use or disclose your protected health information in order to operate this medical practice. These activities include training students, reviewing cases with employees, utilizing your information to improve the quality of care, and contacting you be telephone, email, or text to remind you of your appointments.If we have to share your protected health information to third party “business associates” such as a billing service, if so, we will have a written contract that contains terms that will protect the privacy of your protected health information.We may also use and disclose your protected health information for marketing activities. For example, we might send you a thank you card in the mail with a coupon for specialized services or products. We may also send you information about products or services that might be of interest to you. You can contact us at any point to stop receiving this information. We will not use or disclose your protected health information for any purpose other than those identified in this policy without your specific, written Authorization. You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. You can revoke this authorization at any time but will not affect the protected health information that was shared while the authorization was in effect.
Appointment reminders: We may contact you as a reminder that you have an appointment for your initial visit, follow up visit, or lab work via text, phone or email.
Others Involved in Your Health Care: We may disclose protected health information about you to your family members or friends if we obtain your verbal agreement to do so, or if we give you an opportunity to object to such a disclosure and you do not raise an objection. For example, we may assume that if your spouse or friend is present during your evaluation, that we can disclose protected professional information to this person. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment if there is an urgent or emergent need.
Research: We will not use or disclose your health information for research purposes unless you give us authorization to do so.
Organ Donation: If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation if it is necessary to facilitate this process.
Public Health Risks: We may disclose your protected health information, if necessary, in order to prevent or control disease, report adverse events from medications or products, prevent injury, disability or death. This information may be disclosed to healthcare systems, government agencies, or public health authorities. We may have to disclose your protected health information to the Food and Drug Administration to report adverse events, defects, problems, enable recalls etc. if required by FDA regulation.
Health Oversight Activities: We may disclose protected health information to health oversight agencies for audits, investigations, inspections or licensing purposes. These disclosures might be necessary for state and federal agencies to monitor healthcare systems and compliance with civil law.
Required by Law: We will disclose protected health information about you when required to do so by federal, state and/or local law.
Workman’s compensation: We may disclose your protected health information to workman’s comp or similar programs.
Lawsuits: We may disclose your protected health information in response to a court action, administrative action or a subpoena.
Law Enforcement: We may release protected health information to a law enforcement official in response to a court order, subpoena, warrant, subject to all applicable legal requirements.

YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

Access to medical records: You have the right to access and receive copies of your protected health information that we use to make decisions about your care. You must submit a written request to obtain your protected health information to the individual listed at the end of this privacy policy. We reserve the right to charge you a fee for the time it takes to obtain and copy the protected health information and provide it to you.
Amendment: If you believe the protected health information we have about you is incorrect or incomplete, you may ask us to amend the information. You will need to submit a written request as to why you feel the health information should be amended. We may deny your request to amend if you did not send a written request or give a reason why it should be amended. If we deny your request, we will provide you with a written explanation. We may deny your request if we believe the protected health information is accurate and complete.
Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your personal health information unless the disclosure was used for treatment, payment, healthcare operations, was pursuant to a valid authorization and as otherwise provided in applicable federal and state laws and regulations. You must submit a written request to obtain this “accounting of disclosures” from the individual listed at the bottom of this policy. After your request has been approved, we will provide you with the dates of the disclosure, the name of the individual or entity we disclosed the information to, a description of the information that was disclosed, the reason why it was disclosed, and any additional pertinent information. This information may not be longer than (STATUTE OF LIMITATIONS) years ago prior to the date the accounting is requested. We reserve the right to charge a reasonable fee for this process.
Restriction Requests: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or healthcare operations. We shall accommodate your request except where the disclosure is required by law. We require this be a written request submitted to the individual at the end of this policy.
Confidential Communication: You have the right to request that we communicate with you about healthcare matters in a certain way and at a certain location. We must accommodate your request if it is reasonable and allows us to continue to collect payments and bill you.
Paper copy of this notice: You may request a hard copy of this practice policy if you reviewed and signed it via electronic means. To obtain this copy, contact the individual at the end of this privacy policy.
Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office or with the U.S. Department of Health and Human Services.

PATIENT RIGHTS AND RESPONSIBILITIES

We are committed to serving you with compassion, care, and respect. As one of our valued clients, you are entitled to the following:

You have the right:

To be treated with respect and dignity.
To know the name and professional status of the person(s) serving you.
To privacy and confidentiality.
To receive accurate information about your health-related concerns.
To know the effectiveness and potential side-effects of all forms of treatment.
To participate in choosing the form of treatment best suited to your skin.
To receive education and counseling about treatment.
To review your medical record with your clinician.
To amend your records.
To receive any information about potential services or related services

You have the responsibility:

To seek medical attention promptly, and to provide useful feedback.
To be honest about your medical and social history.
To be honest about your lifestyle risks and exposures.
To ask questions about anything you do not understand.
To follow health advice and instructions.
To report any significant changes in your health.
To respect clinic policies.
To show up for appointments or cancel 48 hours in advance.

By signing this form, I certify:

I have read this form or had this form explained/read to me
I have read or had the Consents for Treatment explained/read to me. I understand its contents, including the risks and benefits of treatment, telemedicine, email use, and voicemail/text appointment reminders.
I give my consent for treatment and accept all associated risks.
I have read or had this Financial Policy explained/read to me. I understand its contents and agree with and accept the terms and requirements.
I have read or had this Privacy Policy / HIPPA Compliance Policy explained/read to me. I understand its contents and agree with and accept the terms and requirements.
I have read or had the Patient’s Rights and Responsibilities explained/read to me. I understand its contents and agree with and accept the terms and requirements.
I have had the opportunity to ask questions and have had them answered to my satisfaction.

ENTIRE AGREEMENT. Member understands and acknowledges that this Agreement represents the entire agreement between both parties. No other oral or written agreements or promises exist between the parties.

Dr. Kristy Riniker, Ikigai Family Physician, LLC

Name __________________________________________________ Date______________________

Signature ___________________________________________________________________________