New Patient Instructions and Acknowledgement

Please take a few minutes to read this form.

Patient Name(Required)

New Patient Instructions and Acknowledgement (required for New Patients)

Thank you for your interest in our clinic. We look forward to serving your health needs. If you have not already done so, you may learn more about our clinic from our website: We require ALL new patients to read and understand the information on this form to avoid any misconceptions or confusion about the services we offer.


Clinic Info:

Providers at Sayana Medical & Wellness Center are trained in a functional & internal medicine framework and alternative ways of preventing disease and illness. Providers are passionate about spending time with patients to discover the root cause of ailments and partner with patients on their healing journey.

Our office does not accept Blue Cross, United, Aetna, Cigna, Health Net, nor HMOs insurance assignment. We are not a Medical Insurance provider. Please contact your insurance company to determine reimbursement for an out of network provider. Additional insurance information is available on the website. It is difficult to provide an estimate for what your total out of pocket expense would be for the course of treatment since it is dependent on many variables.

Professional fees for a provider's consultation time and ancillary services performed by our office are due at the time of making the future appointment. If you fail to show up, these fees are NON REFUNDABLE.

OUT-OF-NETWORK: Initial consultation fees are $429 for Dr. Sayana and $389 for Serena Teddy PA-C and Sara Sawairi FNP-C. During which time, providers will take a detailed medical history and make an initial treatment plan that may include recommendations for lab work and supplements.

IN-NETWORK: If we accept your insurance, a registration fee of $150 will be required PRIOR to making your appointment. If you fail to cancel within our 48 business hour policy OR you miss your appointment, the registration fee of $150 is NOT refundable.

Fees for lab work, follow up consultations, specimen collection and handling, dietary supplements, and other treatments are NOT included in this initial fee.

A follow up appointment is necessary to review progress and lab results. Lab results are not automatically communicated to patients because most specialty lab results require further explanation by the providers. We provide patients with a superbill for office visits or we can submit your superbill to your insurance on your behalf if you have out-of-network benefits. Please contact your insurance company to determine reimbursement for an out of network provider. Your total out of pocket expense would be for the course of treatment since there are many variables.

Insurance for Lab Fees:

Generally, All providers will recommend lab testing, which is NOT included in your consultation fee. Depending on your condition, separate labs may be required and sent to various facilities nationwide. Our primary labs are contracted with most insurance companies and Medicare. Some other labs may be contracted within your insurance network and you will be responsible for network deductibles and copays. Labs may offer cash pricing schemes to limit the maximum out of pocket expense. Some labs do not accept insurance. It is impossible to determine the nature of the labs you may require in advance of your visit. The provider will explain applicable out of pocket lab fees at your visit at your visit.


Patients primarily communicate with providers at there visit. However communication between appts can be done via spruce which is a paid secure online portal messaging system. Our spruce messasing system is HIPPA complaint , your inquiries will be ansered within 72 hours or less, in additonion to offering spruce, we are bundling administrative services not covered by insurance benefits -such as form request( pet letters, disability forms, travel forms ect. The fee is $600 a year OR $65 a month and you pay as you go along (these fees are non refunable), Outside of your scheduled consultation providers are only available to answer brief questions for a fee and this service does not replace a proper consultation for complex medical questions. Direct voice communication with the doctor is not available except for scheduled phone or spruce video consultations. Lab results and patient education material are also communicated electronically. Although phone communication with our office is available, it can be delayed.


We require a 48 hour (business day) notice to cancel or change an initial consultation. We may be able to accommodate (at our option) last minute cancellations or rescheduling by drawing from our waitlist, but you will still be automatically charged $50 for our effort to fill your cancelled appointment since we do not double book appointment slots. You will receive a text confirmation when your appointment is cancelled. You must save this text confirmation.

Credit Card Info:

A credit card authorization is required to book your appointment, if you fail to cancel within our policy or do not come in to your appointment you are considered as a no show and THIS FEE IS NOT REFUNDABLE. This card will be kept on file and used to enforce our cancellation policy described above and future charges. All boxes must be completed.


If a provider offers supplements for your treatment, you are responsible to look into the back of the bottle for ingredients and see if you are allergic to anything or sensitive to any, ONCE supplements are OPEN/UNSEALED we are not able to refund you, you have 30 days to return unopened supplements.

Birth Gender(Required)
MM slash DD slash YYYY
Please enter credit card to hold your appointment. Cancellation fee may apply. See above rules.
Name on credit card
MM/YY of credit card expiration
Security code on card
Mailing Address (Optional. We can get this from you later.)
Put me on the wait list for an earlier appointment.

Upon receipt of this information, the next business day, a staff member will communicate with you. You must then follow further instructions on a few additional forms to complete via text, once ALL forms are completed a staff member will call you to finalize a consultation date and time. Please be advised that sometimes there may be a month wait for a NEW PATIENT appointment. If you do not receive a call back within 24 hours after submitting your additional forms, please call OR text the office 818-331-4386. Thank you. We look forward to meeting you soon.

New Patient Instructions and Acknowledgement will be submitted to Sayana Medical Spa and Wellness Center