Medical Services Informed Consent

You will review and complete this form with a Practice clinician at your first appointment.

You may review the consent form in advance, and we will review it in person as well but you should sign it after the consent has been explained.

Before we may provide medical services to you, the law requires that we obtain your informed consent. You can only provide informed consent to treatment after we have discussed the proposed services, the potential risks of the services, the potential benefits of the services, and information about any potential alternative service options.

Therefore, you acknowledge and agree that the Practice performs Services, and your signature indicates that you consent to receive such Services.

Please tell us immediately if you are pregnant, breastfeeding, post-surgery, taking new medications, have allergies, have chronic liver and/or kidney dysfunction, or have had cosmetic treatments recently.

By signing this form, you represent and warrant that you have truthfully disclosed to us all allergies, your current medication and supplementation regimen, as well as any current and past medical conditions, surgeries, and cosmetic treatments. You agree to inform the Practice immediately of any changes to your current health status and medical conditions.

Summary of Services

Assessment and treatment may include:

Initial evaluations.
IV and IM therapy and add-ons
Weight loss solutions.
Medical Consultations.
Concierge Medicine.
Telemedicine visits
Risks, Benefits, and Alternatives

Depending upon the services you receive, the general benefits of receiving Services may include:

Access to a wide variety of health management services;
Improvement in your conditions or symptoms;
Building a relationship with a healthcare professional can make your visits less stressful and more comfortable.
More hydration.
Increased energy.
Weight loss.
This is Not Your Only Treatment Option

Potential alternatives to receiving these services may include:

Refusal to receive care or halt your treatment; or
Turning to another healthcare provider, including but not limited to a general practitioner or a specialist.
These Services May Pose Risks

Potential risks of these services may include:

Inability to address or treat underlying issues causing medical conditions.
Inability to successfully treat all medical conditions.
Redness, pain, infection at injection sites.
Irritation and/or of the veins/nerves/artery/muscle/other tissue.
Other risks based on the services you agreed to receive may include: Allergic reactions to the components of your treatments, becoming fluid overloaded.
Telemedicine Consent Form
Permission for Telehealth Visits

What is telehealth?

Telehealth is a way to visit with healthcare providers, such as your doctor or nurse practitioner.
You can talk to your provider from any place, including your home. You don’t go to a clinic or hospital.

How do I use telehealth?

You talk to your provider by phone, computer, or tablet.
Sometimes, you use video so you and your provider can see each other.
How does telehealth help me?

You don’t have to go to a clinic or hospital to see your provider.
You won’t risk getting sick from other people.
Can telehealth be bad for me?

You and your provider won’t be in the same room, so it may feel different than an office visit.
Your provider may make a mistake because they cannot examine you as closely as at an office visit. (We don’t know if mistakes are more common with telehealth visits.)
Your provider may decide you still need an office visit.
Technical problems may interrupt or stop your visit before you are done.
Will my telehealth visit be private?

We will not record visits with your provider.
If people are close to you, they may hear something you did not want them to know. You should be in a private place, so other people cannot hear you.
Your provider will tell you if someone else from their office can hear or see you.
We use telehealth technology that is designed to protect your privacy.
If you use the Internet for telehealth, use a network that is private and secure.
There is a very small chance that someone could use technology to hear or see your telehealth visit.
What if I want an office visit, not a telehealth visit?

For now, all visits are by telehealth. You cannot schedule an office visit now due to the lack of a physical location
You must wait until the office opens for all other appointments. We do not know when that will be.
What if I try telehealth and don’t like it?

You can stop using telehealth any time, even during a telehealth visit.
You can still get an office visit if you no longer want a telehealth visit. But until the office opens for all appointments, you will get an office visit only for one of the reasons listed above.
If you decide you do not want to use telehealth again:
call 718-971-9509 and say you want to stop, OR
sign into your patient portal and send your provider a message
It will be as if you never signed this form.
How much does a telehealth visit cost?

What you pay depends on your insurance.
A telehealth visit will not cost any more than an office visit.
If your provider decides you need an office visit in addition to your telehealth visit, you may have to pay for both visits.
Do I have to sign this document?

No. Only sign this document if you want to use telehealth.
Do not sign this form until you start your first telehealth visit. Your provider will discuss it with you.

What does it mean if I sign this document?

If you sign this document, you agree that:

We talked about the information in this document.
We answered all your questions.
You want a telehealth visit.
If you sign this document, we will give you a copy via your patient portal.

As described above, my Practice provider has explained the specific services I, the patient, will receive and their material risks and benefits. I agree and acknowledge that:

The Services may not have the results that I expect or desire;
Provision of Services is not an exact science;
I have not been given any guarantees about the outcomes of receiving Services; and
My Practice Provider has offered me ample time and opportunity to discuss my concerns, and all of my questions have been answered to my satisfaction.
I further acknowledge and agree that:

I have read and understood this entire document;
I have truthfully and to the best of my knowledge provided the information requested;
I am bound by the Practice’s Policies & Procedures;
I am bound by this whole document;
I authorize the Practice’s use of my personal health information to obtain treatment; and
I have received the Practice’s Notice of Privacy Practices.
I understand how to contact my Practice Provider should additional questions arise. My Practice Provider has offered me ample time and opportunity to discuss my concerns, and all my questions have been answered to my satisfaction.

This document may be electronically signed. Electronic signatures on this agreement are the same as handwritten signatures for validity, enforceability, and admissibility purposes.