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. Treatment may include administration of medication, intramuscular injection or insertion of an intravenous catheter and infusion of fluids, vitamins and/or medications as deemed appropriate by the medical staff.
- I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury or even death. I hereby acknowledge that I am aware of all potential risks associated with injection and infusion treatment including, but not limited to, pain, bleeding, swelling at the injection/infusion site, infection, lightheadedness, allergic reaction, bruising and/or even fainting. I acknowledge that no guarantees have been made to me regarding the result of examination or treatment by Concierge MD LA.
- I understand that Concierge MD LA may create a customized therapy to meet my needs. I understand that such custom therapies may not be reviewed or approved by the Food and Drug Administration (“FDA”) or any other entity for safety, quality, or effectiveness. I knowingly and voluntarily consent to such therapies regardless of whether or not they are approved by the FDA or any other entity for safety, quality, or effectiveness.
- I have made the medical staff aware of all my known health conditions, allergies and medications I am taking, including herbal medications/supplements.
- I consent to receiving a medical screening by Concierge MD LA which may occur via telehealth/telemedicine methods and understand that there are certain risks associated with receiving care through telehealth/telemedicine methods. I understand that Concierge MD LA will consult with me about the risks and benefits associated with receiving care through a telemedicine interaction upon my request. I understand that I have the option to withdraw such consent and request an in-person screening without an effect on the access to care I receive from Concierge MD LA.
- 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, I understand that there may be an increase in risk to exposure to my family members and other individuals who live or come to my home. 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.
I acknowledge that I have received a copy of the Notice of Privacy Practice for CONCIERGE MD LA.
3. 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 prior to the commencement of services. 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.
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.
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