Consent To Treat And Financial Responsibility Guarantee
1. CONSENT TO MEDICAL CARE: I hereby authorize the health care providers of Concierge MD LA (“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, stem cells/exosomes, 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 LA, 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.
2. FINANCIAL AGREEMENT AND GUARANTEE: I accept full and complete financial responsibility for all medical services rendered to me and agree to pay for the services in full within 7 days of receiving testing. I further acknowledge, understand and agree that in the event that I fail to make such payments in accordance with the payment policies of the Practice, or in the event of default of my financial obligation to pay for services rendered, the Practice may terminate the “doctor-patient” relationship with me. Furthermore, in the event of my default of my financial obligation, should my account be turned over to an external collection agency for non-payment, I agree to pay any associated collection costs.
If you have any questions concerning, please contact us at [email protected].