CONSENT TO TREAT AND FINANCIAL RESPONSIBILITY GUARANTEE
CONSENT TO MEDICAL CARE:
I hereby authorize the health care providers of Drip Hydration (“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: IV therapy, COVID-19 testing and lab testing. 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 consent to receiving a medical screening via telehealth/telemedicine methods and understand that there are certain risks associated with receiving care through telehealth/telemedicine methods. Furthermore, I have made the medical staff aware of all my known health conditions, allergies and medications I am taking.
- I acknowledge the rendering of care by the staff of Drip Hydration, 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 COVID-19 (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.
- I understand that Drip Hydration 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 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.
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. I understand that the terms herein are contractual and not a mere recital; and that I agree to this document as my own free act and void of any coercion. The permissions granted herein shall begin on the date of acceptance and shall remain effective until terminated by the undersigned. By agreeing to this document I verify that I have read all of the information contained in this Medical Consent Form and that I have asked questions about anything I have not understood up to this point.