CONSENT TO TREAT AND FINANCIAL RESPONSIBILITY GUARANTEE
CONSENT TO MEDICAL CARE: I hereby authorize the health care providers of Concierge MD (“the Practice”) and their staff, to perform any medical diagnostic procedures and medical care which in their professional judgment is deemed necessary to diagnose and/or treat the conditions that have brought about my seeking medical care services from the Practice. I acknowledge that no guarantees are made to me concerning the outcomes of the treatment rendered by the health care providers of the Practice.
- I understand that the services that Practice provides include: Covid-19 testing, IV vitamin therapy, house calls, anti-aging treatments, additional medicine treatment, botox injections, telemedicine, lab testing, functional medicine services, peptides, and in-home detox. I agree that the Practice has communicated to me the risks and benefits associated with each treatment. I am agreeing to undertake and I have had an opportunity to ask the practitioner any questions I have on the risk associated with the treatment I am undertaking. Knowing each of those risks, I am agreeing to be proceed with services from the Practice.
- I acknowledge the rendering of care by the staff of Concierge MD, including the medical doctor, nurse practitioner, physician assistant, nurse or other staff person. Care may include, but is not limited to, obtaining a medical history, performing a physical examination or telemedicine examination, and providing treatment as needed.
- I understand that I am assuming the risk of exposure to the coronavirus (or other public health risk) by having these services provided. Moreover, by inviting the Practice into my home or workplace, I understand that there may be an increase in risk to exposure to other individuals who I am in contact with. I agree to inform the Practice if either myself or anyone I live with or anyone I have been in contact with displays any symptoms consistent with the coronavirus.
TEST RESULTS: Due to imminent business necessity and to ensure the safety of other employees, I consent to being tested for COVID-19 as requested by my Employer and authorize my test results to be released to my Employer. I understand that lab processing can take up to 3-4 days, and the Practice is not responsible for any delays in results once the samples have been delivered to the laboratory. In the event that a sample is not able to be processed, the patient has the option to be retested at the Practice’s office without any service charge except for the lab fee.
FINANCIAL AGREEMENT: (Only Applicable to Employer or Payment Provider) I accept financial responsibility for all medical services rendered to me and agree to pay for the services in full within 3 days of receiving testing. If I fail to make such payments in accordance with the payment policies of the Practice, the Practice may terminate the “doctor-patient” relationship with me. In the event of a default of my financial obligation, the account may be turned over to an external collection agency for non-payment, I understand that the terms herein are contractual and not a mere recital; and that I sign this document as my own free act and void of any coercion. The permissions granted herein shall begin on the date listed below and shall remain effective until terminated by the undersigned. My signature below verifies that I have read all the information contained in this Medical Consent Form and that I have asked questions about anything I have not understood.
