Comprehensive Patient Intake & Consent Form

CONSENT FOR TREATMENT: By this document, I do hereby request and authorize Total Healthcare Clinic (THCC), its medical practices and providers including physicians, technicians, nurses, and other qualified personnel, including appropriately supervised students and residents to perform evaluation and treatment services and procedures as may be necessary in accordance with the judgment of the attending medical practitioner(s). I acknowledge that no guarantee can be made by anyone concerning the results of treatments, examinations or procedures.

TREATMENT OF MINOR CHILDREN: I understand minor children patients must be accompanied by a parent or legal guardian. Charges for services rendered to minor children are the responsibility of the guardian who seeks treatment for the child and are due at time of service(s) regardless of court-ordered responsibility. APPOINTMENTS: Once an appointment has been made, please respect the time that has been reserved in our office schedule for you. There will be a $25.00 charge for missed appointments and appointments not cancelled within 24 hours. We make every attempt to give our patient a courtesy call reminding you of you appointment time, but it is your responsibility to make sure you have this information so you do not miss your appointment.

INSURANCE AUTHORIZATION AND ASSIGNMENT: I request that payment of authorized medical benefits is made on my behalf directly to the THCC provider of service(s) furnished to me. I authorize THCC to release any medical information to my health insurance carrier and/or its legitimate agents that is necessary to process related health insurance claims and/or to verify plan benefits in accordance with HIPAA health information standards. I authorize payment of service(s), otherwise payable to me under the terms of my private, group employer’s or group health insurance plan, directly to THCC. I hereby authorize that photocopies of this form to be valid as the original.

SELF-PAY PATIENTS: I understand if I do not have active coverage or choose not to utilize my insurance benefits, I responsible for all charges occurred at time of service.

LAB RESULTS: If your results are of concern due to abnormal, we will make every effort to promptly contact you. Please be sure this office has your correct telephone numbers. If you are contacted regarding abnormal results, you may be asked to schedule a follow up appointment with your provider. We understand that some patients may not have access to the web or may still want an actual copy. If you wish to obtain an actual copy of your report, you may do so by making prior arrangements with the medical assistant to pick up a copy, which we will leave at the front desk. You may also send in a self-addressed stamped envelope and we will be happy to mail you a copy. We apologize for any inconvenience and thank you for your understanding during this transition. If you do not hear from us within 10 days after completing the test, it is your responsibility to call and obtain these results.

PAYMENT GUARANTEE: I do hereby guarantee payment of all fees and charges related to all services and durable goods provided to me through THCC medical practices and providers from my first date of examination or treatment. I agree to make full payment immediately upon receipt of a THCC billing statement whether it is an interim or final bill. In the event that I fail to make full payment or fail to comply with other payment arrangements made with THCCs approval, I understand that appropriate collection measures may be initiated. I understand and agree that my payments will be processed by a third-party business associate. I hereby consent to have my payment information collected and stored securely

RESTRICTED SERVICE: I understand that all account balances must be in good standing prior to receiving additional services and will contact THCC’s staff if I am unable to pay balance. Past Due Accounts of 60 days or longer may be turned over to a third-party for collection, along with collection costs, attorneys’ fees and court fees. I also understand I may be discharged from the practice.

ADDITIONAL SERVICE CHARGES: Checks may be processed at time of service, if there are insufficient funds available, I understand I will be responsible for providing an alternate payment for the account amount, plus a $35.00 NSF fee.

ELECTRONIC HEALTH RECORD: I understand the following: Healthcare providers require access to patient medical information whenever or wherever a patient presents for care to assure safety, quality and to coordinate patient care across the provider network, avoiding duplication of services. THCC has a system-wide electronic medical record that is available to caregivers on a “need to know” basis, to share information about patient care provided in the hospital, outpatient or physician office settings. Confidentiality of records including those reflecting treatment for behavioral health issues, HIV/AIDS or drug or alcohol problems is maintained per relevant governmental and regulatory standards. Patient care summaries are automatically sent to designated THCC and other community primary care/family/referring physicians, as well as to physicians who are consulted by the attending physician for coordination of care. THCC and/or the attending physician can furnish and release to federal and state healthcare oversight agencies, or upon written request, to all insurance companies or their representatives any information with respect to treatment of the patient herein named including copies of the medical record. I give permission to share my electronic medical record among my healthcare providers and obtain medication history through a Provider Health Information Exchange (HIE). THCC will follow state and federal laws regarding the access by medical providers of any sensitive information, such as behavioral health, substance abuse treatment, sexual abuse, genetic test results, HIV/AIDS status and adoption records.

ELECTRONIC PRESCRIBING: I understand that THCC medical practices and offices may use an electronic prescription system which allows prescriptions and related information to be electronically sent between my THCC providers and my pharmacy. I have been informed and understand that THCC providers using the electronic prescribing system will be able to see information about medications I am already taking, including those prescribed by other providers. I give my consent to my THCC providers to see this health information.

IMMUNIZATION REGISTRY: I understand that THCC participates in the Florida Dept. of Health’s statewide immunization registry that collects vaccination history and information to serve the public health goal of preventing the spread of vaccine preventable diseases. The registry complies with federal health information privacy laws. I do hereby grant permission for THCC to send or fax childhood immunization records to schools, upon request.

CELL PHONES: I hereby consent to provide my telephone number(s), including my wireless telephone number(s), so that representatives from the THCC, its successors or assigns can contact me in any manner including but not limited to by manually placing a call, by using an automatic telephone dialing system or an artificial or prerecorded voice, by texting, or by e mailing, regarding any matter, including but not limited to my medical treatment, prescriptions, insurance eligibility, insurance coverage, scheduling, billing or collection matters. This consent includes any updated or additional contact information that I may provide. I understand that I will be able to change my preference at any time

RELEASE OF RESPONSIBILITY FOR PERSONAL VALUABLES: I have been made aware and understand that all THCC medical practices and offices provide no facilities for safekeeping of valuables. I do hereby release THCC from any responsibility due to loss or damage of any valuables that I, or anyone accompanying me, may bring to a THCC medical practice, office or facility.

NOTICE OF PRIVACY PRACTICES: Required pursuant to Health Insurance Portability and Accountability Act of 1996 (HIPAA), I acknowledge that I have been offered a copy of THCC’s Notice of Privacy Practices. I hereby consent to the use and disclosure of my protected health information, as described in the Notice of Privacy Practices. This will include all of my protected health information generated during hospitalization and outpatient treatment at the Physician Clinic, including but not limited to treatment for mental health, drug and alcohol abuse, communicable diseases such as HIV/AIDS, developmental disabilities, genetic testing, and other types of treatment received.

I, or my legal representative, certify that I have read this document, that it has been fully explained to me and that I understand its contents, and hereby agree to all terms and conditions set forth above and acknowledge the receipt of a copy if requested. The undersigned certifies that s/he has read (or have had read to me) the foregoing, understands it, accepts its terms, and has received a copy of.

I hereby authorize the following procedure: administration of intravenous vitamins, minerals, and other nutrients. This procedure is recommended for replacement of these essential nutrients, correction of deficiencies, and for other therapeutic effects, such as improving immune function, improving antioxidant status, reducing oxidative damage, decreasing bronchospasm, improving fatigue, boosting muscle recovery and energy etc.

I have informed the physician of any known allergies to medications or other substances and of all current medications and supplements. I have fully informed the nurse and/or physician of my medical history.

Intravenous infusion therapy and any claims made about these infusions have not been evaluated by the US Food and Drug Administration (FDA) and are not intended to diagnose, treat, cure, or prevent any medical disease. These IV infusions are not a substitute for your physician’s medical care.

I understand that I have the right to be informed of the procedure, any feasible alternative options, and the risks and benefits. Except in emergencies, procedures are not performed until I have had an opportunity to receive such information and to give my informed consent. 

I understand that:

1. The procedure involves inserting a needle into a vein and injecting the prescribed solution.
2. Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes.
3. Risks of intravenous therapy include but not limited to: a) Occasionally: Discomfort, bruising and pain at the site of injection. b) Rarely: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. c) Extremely Rare: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.
4. Benefits of intravenous therapy include: a) Injectables are not affected by stomach, or intestinal absorption problems. b) Total amount of infusion is available to the tissues. c) Nutrients are forced into cells by means of a high concentration gradient. d) Higher doses of nutrients can be given than possible by mouth without intestinal irritation.

I am aware that other unforeseeable complications could occur. I do not expect the nurse(s) and/or physician(s) to anticipate and or explain all risk and possible complications. I rely on the nurse(s) and/or physician(s) to exercise judgment during the course of treatment with regards to my procedure. I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV Infusion Therapy, including any other procedures which, in the opinion of my physician(s) or other associated with this practice, may be indicated.

This procedure may be considered medically unnecessary. It may or may not mitigate, alleviate, or cure the condition for which it has been prescribed. This therapy has been recommended to you in the belief that it is of potential benefit in these circumstances and its use will quite probably improve the condition for which you are under treatment and in your overall health.

Based on the risks and potential benefits of the current medically indicated treatment(s) and of this proposed treatment, I have elected to forego or supplement the indicated treatment(s) and receive this proposed treatment from the doctors and other health professionals at Total Health Care Clinic as is appropriate and necessary for my care.

I further understand and agree to adhere to the treatment schedule and attend the follow-up visitations set by my medical provider to permit observation and study of my progress. I understand that I may suspend or terminate my treatment at anytime by informing my medical provider. I assume full liability for any adverse effects that may result from the non negligent administration of the proposed treatment. I waive any claim in law or equity for redress of any grievance that I may have concerning or resulting from the procedure, except as that claim pertains to negligent administration of this procedure. The risks involved and the possibilities of complications have been explained to me. I fully understand and confirm that the nature and purpose of the aforementioned treatment to be provided may be considered unproven by scientific testing and peer reviewed publications and therefore may be considered medically unnecessary or not currently indicated.

I hereby place myself under your care for intravenous vitamin therapy. I also verify that all information presented to medical provider in my medical history is true to the best of my knowledge. I am not misrepresenting myself and I place myself under your care for the sole purpose of treatment for these conditions.

Once an appointment has been made, please respect the time that has been reserved in our office schedule for you. There will be a $20.00 charge for missed appointments and appointments not cancelled within 24 hours. We make every attempt to give our patient a courtesy call reminding you of you appointment time, but it is your responsibility to make sure you have this information so you do not miss your appointment.

I hereby acknowledge that I understand that my insurance coverage, including Medicare, may not pay for this non-covered service, and that all services ancillary to this treatment may be also non-covered services and non-reimbursable. I agree to be responsible for payment at the time of service for all non-covered services.

Weight Loss Program Information:

Program Overview:

I understand that I am participating in a medical weight loss program that may include dietary guidance, exercise recommendations, and/or medical interventions. Risks and Benefits: I have been informed of the potential risks and benefits associated with the weight loss program, including but not limited to changes in health, metabolism, and lifestyle. Medical Monitoring: I understand that my progress will be monitored, and adjustments to the program may be made based on my health status and weight loss goals. Informed Consent: Voluntary Participation: I understand that my participation in the weight loss program is voluntary, and I may choose to discontinue at any time. Confidentiality: I acknowledge that my health information will be kept confidential, except as required by law. Release of Information: I authorize the release of relevant medical information to healthcare professionals involved in my weight loss program.

All Statements on this patient intake form are accurate and true to the best of my knowledge. I understand that treatments will be based on the information provided herein. If I willingly withhold knowledge from my treating physician, I accept full liability from any consequences arising there from.

I understand that Total Health Care Clinic has a $25.00 missed appointment fee if I do not give a 24 hour notice. I understand that no agreement can anticipate all events in medical treatment which may arise and that for myself and my heirs, I will hold harmless Total Health Care Clinic and its employees.

Weight-Loss Consumer Bill of Rights (Required by FL. Statue 501.0575)

The weight-loss consumer bill of rights shall consist of the following provisions:

1. Warning: Rapid weight loss may cause serious health problems. Rapid weight loss is more the 1-1/2 to 2 pounds per week or weight loss of more than 1% of body weight per week after the second week of participation in the weight loss program.

2. Consult your personal physician before starting any weight loss program.

3. Only permanent lifestyle changes, such as making healthful food choices and increasing physical activity, promote long-term weight loss.

4. Qualifications of this provider are available upon request.

• You have the right to:

1. Ask questions about the potential health risks of the program and the nutritional content, psychological support and educational comments.

2. Receive an itemized statement of the estimated price of the weight loss program, including extra products, services, supplements, examinations and laboratory tests.

3. Know the actual or estimated duration of the program.

4. Know the name, address and qualifications of the physician, dietitian or nutritionist who has received and approved the weight loss program according to Florida statue 468.5055(1)(1).