General Informed Consent for Treatment

Cancellation Policy
Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the nurse’s day that could have been filled by another patient. The nurse may have already traveled to your location, prepared in-clinic and your service may have already been dispensed. As such, we ask for 24 hours’ notice for any cancellations or changes to your appointment. Guests who provide less than 24 hours’ notice or miss their appointment will be charged a cancellation fee of $100 mobile or $50 for clinic, telehealth and other non-mobile services.

Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE OBTAINED, USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY.

Treatment: Your health information may be used by staff members or disclosed to other health care professionals for the purpose of reviewing your health and providing therapies. Liquid, LLC., its agents and assigns do not evaluate health or diagnose medical conditions, but instead recommend that all patients refer such issues of evaluation and diagnosis to their primary care or specialty physicians. For example, results of laboratory tests and procedures will be available in your medical record to all health professionals and Liquid employees and affiliates who may provide therapies or who may be consulted by staff members.

Payment: Your health information may be used to seek payment from your HSA, banking institutions and credit card companies that you may use to pay for services. Your health information may also be disclosed to other health care providers to assist them in obtaining payment for services they have provided to you.

Health care operations: Your health information may be used as necessary to review and adjust the day-to-day activities and management of Liquid. For example, information on the services you received may be used to support budgeting and financial reporting, fraud and abuse detection and compliance programs, and activities to evaluate and promote quality. We may also share your health information with other healthcare providers when they request this information to help them with their quality assessment and improvement activities, their patient-safety activities, their population-based efforts to improve health or reduce health care costs, their protocol development, case management or care-coordination activities, their review of competence, qualifications and performance of health care professionals, their training programs, their accreditation, certification or licensing activities, or their health care fraud and abuse detection and compliance efforts. We may also share your medical information with our “business associates” that perform administrative services for us. We have a written contract with each of these business associates that contains terms requiring them and their subcontractors to protect the confidentiality and security of your medical information.

Law Enforcement: Your health information may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law-enforcement investigations, to comply with government mandated reporting, and for other law enforcement purposes.

Public Health Reporting: Your health information may be disclosed to public health agencies as required by law. For example, we are required to report certain communicable diseases to the state’s public health department. When we report suspected elder or dependent adult abuse or domestic violence, we will inform you or your personal representative promptly unless in our best professional judgment, we believe the notification would place you at risk of serious harm or would require informing a personal representative we believe is responsible for the abuse or harm.

Required by Law: As required by law in certain circumstances other than public health reporting, your health information may be used and disclosed by our staff, but such use and disclosure will be limited to the relevant requirements of the law concerning such specific circumstances. Further, in the case of a breach of unsecured protected health information, we will notify you as required by law.

Additional Uses of Information Appointment reminders: Your health information will be used by our staff to send you appointment reminders. Information about therapies and services: Your health information may be used to send you information on the therapies and services available and general health information that you may find to be of interest. We may also send you information describing other health-related goods and services that we believe may interest you.

Other Uses and Disclosures: Require your Authorization Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. Even if you provide this written authorization, you are always free to change your mind at a later date regarding the authorization. If you change your mind after authorizing a use or disclosure of your information, you may submit a written revocation of the authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us of your decision.

Individual Rights
You have certain rights under the federal privacy standards. These include:

  • The right to request restrictions on the use and disclosure of your protected health information by a written request specifying what information you want to limit, and what limitations on our use or disclosure of that information you wish to have imposed. We may not be required to agree to the restriction that you requested due to limitations contained in the applicable laws and we will notify you of our decision to reject your request;
  • The right to receive communications from us concerning the service and therapies received by you and your health information through reasonable, confidential alternative means selected by you;
  • The right to inspect and copy your protected health information. To access your medical information, you must submit a written request detailing what information you want access to, whether you want to inspect it or get a copy of it, and if you want a copy, your preferred form and format. We will provide copies in your requested form and format if it is readily producible, or we will provide you with an alternative format you find acceptable. We will charge a reasonable fee which covers our costs for labor, supplies, postage, and if requested and agreed to in advance, the cost of preparing an explanation or summary, as allowed by applicable law. We may deny your request under limited circumstances;
  • The right to amend or submit corrections to your protected health information by submitting a written request including the reasons you believe the information is incorrect or incomplete. We are not required to change your health information and will provide you with information regarding our denial of such requested amendment. If we deny your request, you may submit a written statement of your disagreement with that decision, and we may, in turn, prepare a written rebuttal.
  • The right to receive an accounting of how and to whom your protected health information has been disclosed; provided, however, we are not required to provide to you an accounting of disclosures made for the purposes of treatment, payment, health care operations, information provided directly to you, information provided pursuant to your written authorization, and certain government functions.
  • The right to receive a printed copy of this notice.
  • If for any reason there is an unauthorized use/disclosure of your protected health information, you will receive written communication from our office.

Special Situations

  • Military, Veterans, National Security and Intelligence: If you are or were a member of the armed forces, or part of the national security or intelligence communities, we may be required by military command or other government agencies to disclose your medical information.
  • Worker’s Compensation: We may release protected health information about you for worker’s compensation or similar programs. These programs provide benefits for work-related injuries or illness.
  • Health Oversight Activities: We may disclose protected health information to a health oversight agency for audits, investigations, inspections, or licensing purposes. These disclosures may be necessary for certain state and federal agencies to monitor the health care system, government programs, and compliance with civil rights laws.
  • Lawsuits and Disputes: If you are involved in a lawsuit or a dispute, we may disclose health information about you in response to a court or administrative order. Subject to all applicable legal requirements, we may also disclose health information about you in response to a subpoena.
  • Law Enforcement: We may release protected health information if asked to do so by a law enforcement official in response to a court order, subpoena, warrant, summons or similar process, subject to all applicable legal requirements.

Messaging Terms & Conditions
Messaging through email, text and calling is done to keep you informed on appointments, bookings, upcoming services and other information that may be pertinent to your wellness needs. By signing this consent, you are agreeing to receive recurring automated marketing and informational text messages from Liquid Mobile IV for Liquid Mobile. Automated messages may be sent using an automatic telephone dialing system to the mobile telephone number you provided when signing up or any other number that you designate.

Message frequency varies, and additional email and mobile messages may be sent periodically based on your interaction with Liquid Mobile. Liquid Mobile reserves the right to alter the frequency of messages sent at any time to increase or decrease the total number of sent messages. Liquid Mobile IV also reserves the right to change the short code or phone number where messages are sent.

Message and data rates may apply. If you have any questions about your text plan or data plan, it is best to contact your wireless provider. Your wireless provider is not liable for delayed or undelivered messages. Your consent to receive marketing messages is not a condition of purchase.

Carriers are not liable for delayed or undelivered messages.

You can cancel any time by texting “STOP”. After you send the SMS message “STOP”, we will send you a message to confirm that you have been unsubscribed and no more messages will be sent. If you would like to receive messages from Liquid Mobile IV again, just sign up as you did the first time and Liquid Mobile IV will start sending messages to you again. You can also click “Unsubscribe” or reply with “Opt-out.”

Text “HELP” at any time and we will respond with instructions on how to unsubscribe. For support regarding our services, email us at [email protected].

You agree that before changing your mobile number or transferring your mobile number to another individual, you will either reply “STOP” from the original number or notify us of your old number at [email protected]. The duty to inform us based on the above events is a condition of using this service to receive messages.

If you have any questions about your data or our privacy practices, please visit our Privacy Policy at https://liquidmobileiv.com/privacy-policy/

We reserve the right to change or terminate our messaging program at any time. We also reserve the right to update these Messaging Terms at any time. Such changes will be effective immediately upon posting. Your continued enrollment following such changes shall constitute your acceptance of such changes.

Liquid Duties

  • We are required by law to maintain the privacy of your protected health information and to provide you with this notice of privacy practices.
  • We also are required to abide by the privacy policies and practices that are outlined in this notice.

 

Rights to Revise Privacy Practices
As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies and practices may be required by changes in federal and state laws and regulations. Whatever the reason for these revisions, we will provide you with a revised notice on your next office visit. The revised policies and practices will be applied to all protected health information that we maintain, regardless of when it was created or received.

Requests to Inspect Protected Health Information
As permitted by federal regulation, we require that requests to inspect or copy protected health information be submitted in writing. You may obtain a form to request access to your records by contacting us.

Complaints
If you would like to submit a comment or complaint about our privacy practices, you can do so by sending a letter outlining your concerns. You also have the right to submit a complaint to the Secretary of the Department of Health and Human Services if you believe your privacy rights have been violated.

Our contact information is:
Liquid Mobile IV
11775 W. 112th St.
Overland Park, KS 66210
855.954.7843

Gift Card Terms & Conditions
The gift card shall be valid for 1 year from the date of issue. Gift cards must be submitted before the service and upon check-in. The original gift card is required; copies or scans of gift cards shall not be considered valid. Please treat this card like cash; if this card is lost or stolen it will not be replaced. Use of this gift card can be redeemed only at Liquid Mobile. This card cannot be exchanged for cash, check or credit. Please treat this card like cash; if this card is lost or stolen it will not be replaced. Redeemable only for goods and services not exceeding the remaining credit balance on this card. Treat this card as cash; if it is lost, it will not be replaced. This card is property of the issuer. Treat this card as cash. It will not be replaced if lost or stolen. This card is redeemable for merchandise only. Redeemable at Liquid Mobile location. This card is redeemable by the bearer for merchandise or services at Liquid Mobile. It may not be returned or redeemed for cash. Please treat this card like cash; it is not replaceable if lost, stolen or if used without authorization. If this card is not used for a period of 12 months from the issue date, it will no longer be accepted. Treat this card as cash; it will not be replaced if lost or stolen. It is redeemable only at the locations purchased from. Your use of this gift card constitutes acceptance of these terms. This card is not exchangeable for cash or replaced if lost or stolen. Present at the Liquid Mobile location for the purchase of goods or services that qualify and are tied to the purpose of this gift card.

Refer a Friend Terms & Conditions
This agreement describes the terms and conditions for participation in the Liquid Mobile refer a friend program. In this agreement, the term “you/your” refers to you (the referring user), the term “user” refers to the user being referred and the term “Liquid Mobile” refers to Liquid LLC., with whom you are entering this agreement. By using the Liquid Mobile referral program you are confirming that you have read this agreement and agree to our terms and conditions. General Terms:  A user must use your unique link to purchase a plan in order to qualify for the program. Users have 30 days to make a purchase using your link for a reward to be awarded. Credits can be used against purchasing a qualified service from Liquid. You cannot transfer credits to another user or account. You cannot withdraw credits from your account in any form. You cannot refer yourself. We reserve the right to change this policy at any time and without notice. You cannot use a refer a friend discount in conjunction with any other offer. For a friend to generate credit, the customer must complete their purchase and remit full payment for the product. Credits will only be applied on sales that are made when the uses a valid, correctly structured referral link. Properly structured links are your sole responsibility. Refunds are not applicable. You may not post your referral links on social media platforms. You may not use your referral link in any bulk email messages or spam. You may not post your referral link to any public forums or websites. Liquid retains the right to cancel this promotion at any time and without notice. We may modify any of the terms and conditions within this Agreement at any time and at our sole discretion. These modifications may include but are not limited to changes in the scope of available credits, schedules, and program rules.

Informed Consent – COVID 19 Pandemic
I understand that I am opting for a service with Liquid that is not urgent and may not be medically necessary.

I also understand that the novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. I further understand that COVID-19 is extremely contagious and is believed to spread by person-to-person contact; and, as a result, federal and state health agencies recommend social distancing. I recognize that the physician and all staff at Liquid are closely monitoring this situation and have put in place reasonable preventative measures aimed to reduce the spread of COVID-19. However, given the nature of the virus, I understand there is an inherent risk of becoming infected with COVID-19 by virtue of proceeding with this service. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this service, and I give my express permission for Liquid physician and staff to proceed with the same.

I understand that, even if I have been tested for COVID and received a negative test result, the tests in some cases may fail to detect the virus or I may have contracted COVID after the test.

I understand that, if I have a COVID-19 infection, and even if I do not have any symptoms for the same, proceeding with this service can lead to a higher chance of complication and death.

I understand that possible exposure to COVID-19 before/during/after my service may result in the following: a positive COVID-19 diagnosis, extended quarantine/self-isolation, additional tests, hospitalization that may require medical therapy, Intensive Care treatment, possible need for intubation/ventilator support, short-term or long-term intubation, other potential complications, and the risk of death. In addition, after my elective treatment/procedure/surgery, I may need additional care that may require me to go to an emergency room or a hospital.

I understand that COVID-19 may cause additional risks, some or many of which may not currently be known at this time, in addition to the risks described herein, as well as those risks for the service itself. I have been given the option to defer the service to a later date. However, I understand all the potential risks, including but not limited to the potential short-term and long-term complications related to COVID-19, and I would like to proceed with my desired service.

Liquid Practice Policy and Acknowledgement of Provider
You will be evaluated by a trained and licensed nurse that is overseen by a provider to ensure that it is appropriate to provide you with this service. We wish to take this opportunity to welcome you and to state some basic principles we believe are essential in establishing a good relationship between us. Please read through this information, ensure that you are comfortable with it and feel free to ask questions, as needed.

  • INITIAL INTERVIEW: Your first history and physical is considered an evaluation interview and exam. At the time of this appointment, the following decisions will be made with you regarding the provision of our services:

1.a) If your requested service is appropriate based on the information you disclosed
2.b) Frequency of the service to be provided
3.c) Goals of service (what you hope to gain from this process)

  1. APPOINTMENTS: Each appointment varies in length depending on your request. Typically, service appointments take just under 1 hour. At the end of each appointment, you can make arrangements for your next appointment, or you may also book all your appointments at once.
  1. CANCELLATIONS: Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the nurse’s day that could have been filled by another patient. The nurse may have already traveled to your location, prepared in the clinic and your service may have already been dispensed. As such, we ask for 24 hours’ notice for any cancellations or changes to your appointment. Guests who provide less than 24 hours’ notice or miss their appointment will be charged a cancellation fee of $100 mobile or $50 for clinic, telehealth and other non-mobile services.
  1. PAYMENTS: Payment in full for each appointment is required prior to the start of your appointment. We accept credit cards, electronic payments, as well as cash.
  1. NO INSURANCE: We do not currently bill for or accept insurance payments for our services.
  1. PETS: Pets must be put away, and not have access to the Guest being assisted, the nurse or the supplies. This is for the safety and protection of everyone involved.
  1. CONFIDENTIALITY: All information regarding the specific nature of your treatment is maintained within the HIPAA compliant Electronic Medical Record and is considered confidential, and will not be disclosed to anyone. unless otherwise authorized by law or by written authorization by you. However, each provider at this office reserves the right to use specialty consultation with other medical providers affiliated with Liquid. We follow all requirements and guidelines of HIPAA regarding protected health care information and security of that information.

Membership Consent
If enrolled in a membership, I authorize Liquid to bill and generate charges to my credit card of record for all relevant services provided and to automatically renew my membership fee unless prior written cancellation is received prior to the due date of membership payment. Memberships do have a two-month minimum enrollment requirement.

Informed Consent for Treatment
Liquid provides multiple medical services, including, but not limited to: intravenous and injection therapies, labs, weight management, telehealth, hormone therapies, and aesthetics. A trained Liquid nurse, nurse practitioner or physician administers the services under the direction of a licensed physician. You have the right to be fully informed of the detailed process of the services, as well as the benefits and any potential risks of the services and may refuse to proceed with the service at any time during the process.

Informed Consent for Intravenous, Intramuscular IV Therapy, Injections and Labs
Intravenous therapy involves inserting an intravenous catheter and administering intravenous substances through the vein. Intramuscular or subcutaneous injection therapy involves injecting substances directly into a muscle or subcutaneous tissue. Lab tests involve, but are not limited to swabs, and blood draw.

These treatments are recommended to facilitate the replacement of essential nutrients, correction of nutritional deficiencies, provision of medications and for other health promoting services, such as assisting with improving immune function, improving antioxidant status, reducing oxidative damage, and improving energy. These treatments are not considered medically necessary and are not intended, warrantied or guaranteed to cure any major disease, defect or ailment that you may have. They may not mitigate, alleviate, or treat any medical condition. These treatments have been recommended for their health promoting benefits and their use is intended to support and improve the condition of your overall health.

Benefits of intravenous therapy, injections may include:

  • Increases Hydration
  • Increases cellular metabolism and health
  • Helps achieve optimum health by restoring depleted vitamin and mineral levels
  • Supports the immune system

Benefits of having lab test drawn and performed may include:

  • Provide valuable baseline information of Patient Condition
  • May help determine viability and suitability of Patient for other options of care
  • Provide your primary medical team with lab information to assist them with your routine care

Side Effects/Risks

Although rare, there are some risks associated with intravenous therapy, injections and labs. Including:

  • The procedure involves inserting a needle into a vein and injecting the prescribed solution.
  • Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes.
  • Risks of intravenous therapy, injections and lab testing include but not limited to:
  • Occasionally to commonly:
    • Discomfort, bruising and pain at the site of injection or lab draw.
    • General feeling of warmth during and after injection
  • Rarely:
    • Inflammation of the vein used for injection or lab draw, phlebitis, metabolic disturbances, and injury.
    • Reactive Hypotension (or rapid drop in blood pressure) iii. Reactive Hypoglycemia (or rapid drop in blood sugar)
  • Extremely Rarely: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.

The Procedure
The intravenous procedure involves inserting a needle into your vein and infusing the solution of prescribed nutrients (vitamins, minerals, amino acids, medications) or chelation agents over a determined period of time.

An intramuscular injection involves injecting the agent into the muscle.

A lab test involves but is not limited to swabs and blood draws.

Prior to treatments, often, your vitals signs will be measured. In the instances were Patient is infused with any substance, vital signs will be taken after the treatment as well.

What Safety Precautions Must You Take?

  • Check with your primary care provider and medical team prior to any service request.
  • Understand your responsibility to ensure your primary care provider and your medical team are aware of all lab results and outcomes of services provided.
  • After therapy or lab draws are provided, monitor the insertion site for signs and symptoms of infection (redness, swelling, discharge). If any of these signs are identified, notify Liquid immediately. If you experience a sustained fever greater than 101, do not delay treatment and go to the ER as this can be a sign of severe condition, including but not limited to sepsis.
  • If you experience a minor side effect while you are at home, you should contact the Liquid, otherwise contact your medical provider or call 911.
  • For emergent situations, dial 911.

My Consent for Nutrient Infusion, Intramuscular Injections, Lab Testing is Voluntary. My request for nutrient infusion, intramuscular injections, lab testing as described above is entirely voluntary and I have not been offered any inducement to participate or provide this consent. I understand that I may refuse to participate in this therapy at any time during this process.

Informed Consent for Weight Management Inclusive of General Informed Consent

  • I voluntarily request that Liquid provide this treatment for my condition.
  • I have informed my provider of any known allergies, all my medical conditions, current medications, social/family history.
  • I have the right to be informed of any alternative options of treatment, side effects, and the risks and benefits.
  • I have had the mechanics and expected effects of the medication.
  • I understand how it is to be administered.
  • I understand the prescription may come from a compounding pharmacy, which is not FDA approved. I have been told that the manufacturing facility itself is FDA monitored along with third party testing on the medication itself.
  • Prices may vary and change. The charge for my services will include my time with Liquid, including communication outside of the office, supplies, and medication.
  • Liquid may change the pharmacy based on several factors (availability, shipping time, cost) which could have an impact on pricing.
  • It has been explained to me that this medication could be harmful if taken inappropriately or without following the advice from the provider.
  • I understand this medication may cause adverse side effects (see below). I understand this list is not complete and it describes the most common side effects, and that death is also a possibility of taking this medication. I understand symptoms may be worse after there has been a change in my medication dose or when first starting the medication.

Common side effects include, but are not limited to:

  • Gastrointestinal: Nausea/vomiting, abdominal pain, Diarrhea/constipation, dyspepsia, abdominal distension, eructation, flatulence, gastroenteritis, GERD, gastritis, lipase increase, amylase increase
  • Neurological: Headache, dizziness
  • Cardiac: Heart rate increase, Hypotension
  • Endocrine: Fatigue, hypoglycemia (diabetic patients), alopecia
  • Ophthalmic: Retinal disorder (diabetic patients)
  • Skin: redness or pain at injection site

Serious Reactions include, but are not limited to:

  • Thyroid C-cell tumor (animal studies)
  • Medullary thyroid cancer
  • Hypersensitivity reaction
  • Anaphylaxis
  • Angioedema
  • Acute kidney injury
  • Chronic renal failure exacerbation
  • Pancreatitis
  • Cholelithiasis
  • Cholecystitis
  • Syncope
    1. I understand that I have the following responsibilities:
    2. I agree to abide by and follow the instructions and guidance provided in my treatment, including receiving and obtaining prescriptions for weight management.
    3. I will provide Liquid with all necessary information regarding my preference of pharmacy for my prescription.
    4. If I am later looking to transition to another pharmacy, I will let Liquid know in advance
    5. If I determine that I would like to seek insurance coverage for my treatment, I will tell Liquid in advance of providing any treatment to me.
    6. Medical history: I will be candid and honest in providing my complete medical history, including: allergies, medications, disease history to Liquid.
    7. I understand that if I become pregnant or start trying to become pregnant, I will immediately notify Liquid and I will stop ingesting any medication prescribed to me by Liquid.
    8. I understand my responsibility to timely notify and update all medical staff with any new health information (medication, allergies, personal medical issues/surgeries/social history, or family history changes).
    9. I authorize Liquid to discuss my treatment plan with any co-treating pharmacist and/or healthcare provider.
    10. I will always tell other providers about all medications I am taking.
    11. Directions for use: I will take my medications only as prescribed, and according to the directions provided by Liquid.
    12. If I feel my medications are not effective, or are causing undesirable side effects, I will contact Liquid immediately for instructions and guidance.
    13. I will not adjust the dosage of my medications without prior consultation and instruction to do so.
    14. I understand that some medication must be either kept frozen or refrigerated to maintain effectiveness and assume responsibility to do so.
    15. I understand that, to be effective, this medication must be self-injected in the subcutaneous tissue once weekly. I understand that it is my responsibility to ensure that my injections do not occur more frequently than every 7 days, unless directed by Liquid.
    16. It is my responsibility to follow infection and safety protocols regarding my medication and I will not share needles and only dispose of needles in a safe manner.
    17. If I’m having troubles with the administration of the medication, I will notify Liquid as soon as possible for assistance and guidance.
    18. If the medications expire, I will refer to the Beyond Usage Date (BUD) information and contact the pharmacy or my provider.

Refills:

  • I understand that obtaining refills of my medication may require an appointment.
  • I understand, I may need to schedule refill appointments ahead of time to avoid delays in refills or running out of my medication.
  • For my own safety, I will not ask for refills of my medication prior to the appropriate time.
  • I understand that I may be asked to bring the medication with me to my appointments to verify my appropriate administration of my medications, check the quantity remaining and assess my injection procedures.

 

 

Safety:

  • I understand it is important to keep my medication away from children (Anyone <18 years old)
  • I am the only one who will use my medication. I will not give or sell my medication to anyone else.
  • I will check with my primary care provider and medical team prior to any service request.
  • I understand it is my responsibility to keep my primary care provider and medical team aware of all lab results, services requested and outcomes of services provided.
  • If Liquid deems it appropriate for me to start weaning my medication or transition to maintenance dosing, I will comply.

 

Discontinuation of medication: I understand that Liquid may stop prescribing my medications if:

  • I am having unfavorable side effects or it’s not working to address the intended condition.
  • I have been untruthful or incomplete in my provision of my medical or family history.
  • I have achieved the goal of the service.
  • I am deemed non-compliant with the recommended plan of care set by Liquid.
  • I do not follow any aspect of my responsibilities under “Part B” in this agreement.

I have read this form in its entirety. It has been explained to me. I have had the opportunity to ask questions and have all my questions answered. I fully understand the above information and have no further questions. By signing this form, I voluntarily give my consent for treatment, understand, and agree to the risks.

Informed Consent for Aesthetic Procedures  Inclusive of General Informed Consent

Liquid also provides aesthetic procedures, including neurotoxin injections, dermal filler injections, and microneedling/microchanneling. A trained Liquid clinician administers aesthetic therapies under the direction of a licensed physician. You have the right to be fully informed of the detailed process of the therapy, as well as the benefits and any potential risks of the therapy. You may refuse to proceed with the therapy at any time during the process.

Aesthetic procedures are considered elective procedures customized for each individual to aid in the management of  the following:

  • Botulinum toxin injections for facial dynamic wrinkles, sweating, TMJ dysfunction, bruxism, hyperhidrosis and types of orofacial pain, including headaches and migraines.
  • Dermal fillers for facial rejuvenation, lip enhancement, establishing proper lip and smile lines, and replacing facial volume.
  • Microneedling/Microchanneling for reducing fine lines and wrinkles, sun damage and pigmentation, stretch marks, and surgical and acne scars.

 

Side Effects/Risks

Before undergoing an aesthetic procedure, understanding the risks is essential. No procedure is entirely risk-free. The risks detailed in the Aesthetic Service Consent may occur, but there may also be unforeseen risks and risks that are not included in this list.

  • Neurotoxin Treatment Risks: 1. Post treatment discomfort, swelling, redness, and bruising 2. Double vision 3. A weakened tear duct Post treatment bacterial and/or fungal infection requiring further treatment 5. Allergic reaction 6. Minor temporary droop of eyelid(s) in approximately 2% of injections.  This usually lasts 2-3 weeks 7. Occasional numbness of the injection area lasting up to 2-3 weeks 8. Transient headache and Flu-like symptoms may occur
    • Further treatment for additional improvement or correction of side effects or complications may be necessary. I understand I am responsible for all such costs.
  • Dermal Filler Treatment Risks: 1. Post-treatment discomfort, swelling, redness, bruising, and discoloration 2. Post-treatment infection associated with any transcutaneous injection 3. Allergic reaction 4. Reactivation of herpes (cold sores) 5. Lumpiness, visible yellow or white patches 6. Granuloma formation 7. Localized necrosis and/or sloughing, with scab and/or without scab, if a blood vessel occlusion occurs, potentially an occlusion could cause a heart attack, stroke, or blindness.
    • Further treatment for additional improvement, or correction of side effects or complications may be necessary. I understand I am responsible for all such costs. I understand that the majority of humans have facial asymmetry and therefore, perfect symmetry is unrealistic in most cases
  • Microneedling/Microchanneling: 1.Discomfort at the treatment site with transient redness and swelling which may last up to two hours or longer. 2.The redness may last up to 2-3 days. The treated area may feel like a sunburn for a few hours after treatment. 4. Increased or decreased pigmentation is possible and can take 3 to 6 months or more to resolve. 5. Loss of pigmented lesions such as freckles may give the appearance of loss of pigment. 6. Small areas of scabbing may occur 2-3 days following the treatment. 7. Infection is possible if proper aftercare guidelines are not followed. 8. Milia/acne formation with use of ointments that occlude hair follicles, sweat ducts, or sebaceous ducts. 9. Risk of burning, blistering, or bleeding of treatment areas with picking or scratching the sites
    • I understand that although I may see a change after my first treatment, and results vary, microneedling/microchanneling treatments are not permanent. Additional treatments are recommended to achieve the best results.
  • If you experience any of the side effects or risks detailed in the Aesthetic Service Consent you should contact Liquid immediately, contact your medical provider or call 911
  • For emergent situations, dial 911

 

The Procedure and Results

Your trained Liquid practitioner will thoroughly explain the details of your selected procedure and the intended results before the treatment administration. Following your treatment, your practitioner will review post-treatment precautions and instructions to follow. Treatment plans are created specific to each individual, and the results are not guaranteed. With aesthetic services like Neurotoxin injections, dermal fillers, and microneedling/microchanneling, repeat treatments are often required to obtain optimal results and will be recommended based on your specific treatment plan. The duration of your results may vary by procedure and individual response to products. Please refer to the Aesthetic Service Consent for details on each service procedure and expected results.

 

Aesthetic treatments are a visually oriented specialty. As such it is necessary that photographs be taken before, during, and after an aesthetic procedure or treatment. This allows for proper planning before procedures and follow-up evaluation afterward. Photographs are required only for the body part in question.  Due to the nature of aesthetic procedures and treatments, this may include the face. Consent is required to take such images.

My Consent for Aesthetic Services is Voluntary. My request for Aesthetic services as described above, is entirely voluntary and I have not been offered any inducement to participate or provide this consent. I understand that I may refuse to participate in this therapy at any time during this process.

 

Informed Consent for Telehealth Inclusive of General Informed Consent

Telemedicine involves the use of electronic communication to enable virtual consultations. During your virtual consultation, details of your medical history, examinations and tests, as well as treatment will be discussed via the use of interactive video, audio, and/or telecommunication technology. Video and/or audio, or photographs may be taken of you during the virtual consultation by the clinician for your medical record.  All records are maintained confidential in compliance with the practitioners regulatory standards and not released without your consent. The purpose of this is to obtain your consent to participate in telemedicine consultations.

 

While we take every precaution to ensure the privacy and confidentiality of your virtual consultation, there are inherent privacy and confidentiality risks involved in the use of telemedicine. Due of the risks outlined below, we cannot guarantee the security and confidentiality of your virtual consultation:

  • Use of electronic communications to discuss sensitive information can increase the risk of inadvertent disclosure of such information to 3rd parties.
  • Electronic communications can be forwarded, intercepted, circulated, stored, or even changed without the knowledge or permission of the participants.
  • Employers and online services may have a legal right to inspect and keep electronic communications that pass through their system.

 

Signing this consent form provides us with your permission to communicate with you via telemedicine. Additionally:

  • I understand that Liquid cannot guarantee the security of the telemedicine platform.
  • I undersand and agree that individual care providerrs may make decisions about my treatment based on information I provide through telemedicine which will become part of my health record.
  • I understand that I may stop using telemedicine for communication purposes at any time, at which point I will inform Liquid in writing.
  • I understand that individual care providers may stop using telemedicine for communication purposes at anytime which will be communicated in writing or at a clinic appointment.

 

 

Informed Consent for Hormone Therapy Inclusive General Informed Consent

Liquid Hormone Services Consent

I, the undersigned, have reviewed this form, understand its contents and hereby authorize and give my Informed Consent for the administration of hormone replacement therapy.

 

This informed consent form provides written information regarding the risks, benefits, and alternatives of the procedure named above. This material serves as a supplement to the discussion you have with your healthcare provider. Prior to giving consent, it is important that you fully understand this information, so please read this document thoroughly. If you have any questions regarding the procedure, ask your healthcare professional before signing the consent form.

 

Guest Service Agreement

The Program provides a comprehensive solution to men’s and women’s hormonal health concerns. Patients will receive telemedicine consultations with a qualified physician, nurse practitioner or other licensed healthcare professional. Services include comprehensive assessments, prescription ovarian

hormones, dosage adjustments, and laboratory testing for the purpose of obtaining optimal results.

 

Our method is a rigorously refined methodology that has embraced the strategies of safety and efficacy for 26 years and is a critical component of the success of hormone therapies.  For example, our topical ovarian hormone prescriptions are compounded and dispensed in our proprietary organic oil formulation. We use compounding pharmacies that are trained in our methods and use our proprietary topical organic base to achieve the best results. For bioidentical hormone therapy to be effective, this process relies on a commitment from the Patient to participate in regular telemedicine consultations, testing, and monitoring as we support you on this journey.

 

The therapeutic objective is to replenish and balance your hormones to the levels

necessary to alleviate hormonal insufficiencies, menopausal symptoms and restore the

protections that hormones can provide over the short and long term. We understand that hormone issues are unique to the individual, so the care provided is highly personalized as well.  Determining optimal therapeutic dosages cannot be done in isolation, but requires that a Patient be followed and have regular access to their prescribing provider, particularly during the initial months, as well as during periods of change, as the optimal dosages are determined and tested. In order to ensure the coordination of these levels of care, the Patient must be willing to allow all relevant providers access to care records and relevant information.

 

Please note that while we will work with you to thoroughly address your issues related to

hormone insufficiency, menopause, and hormone replenishment, we do not provide general medical care. Our medical services do not extend beyond managing hormonal therapies. It will be your responsibility to address any health and medical issues beyond this therapy with the appropriate health care professionals.

 

This Patient Agreement allows Patients, for a single monthly fee, to have telemedicine access, as needed, to a qualified appropriately licensed physician or nurse practitioner to   determine appropriate compounded Bioidentical Hormone Replenishment Therapy (“cBHRT”).  This telemedicine process will include comprehensive evaluation and follow-up telemedicine consultations to determine the proper dosing according to our method.

 

Services include:

  • An initial evaluation and design of the treatment program. This is a thorough process, as getting hormones right can take time. Your initial consultation will be the most extensive. Two or more additional consultations will be required during your initial dose determination and test confirmation process over the first 3-5 months. Prior to your first consultation, you will complete our initial questionnaire and provide us with valuable and recent or relevant background information, as well as medical reports such as blood tests, imaging studies, etc.
  • Follow-up consultations for dose adjustment and hormone testing. These consultations will be considerably shorter but as frequent as necessary.
  • Hormone prescription costs are included in the monthly fee.

 

Fees

The fees for this service include (1) an onboarding and one-time fee of $50 (2) a monthly

Patient payment of $199 per month for the first year. Payment is due on the first day of registration, then monthly thereafter and will be billed to the credit card on file. Additional fees would be incurred for the cost of thyroid hormones, if needed.

 

Additional Terms and Conditions

Release of Medical Assessments.

Patients will provide our Practitioner with the following information:

  • An initial and an annual physical and female examination performed by your own primary care provider (“PCP”) or gynecologist (“GYN”). You will need to authorize your PCP or GYN to release pertinent medical records to us, including records of any recent physical examinations, relevant lab tests, and/or imaging studies.
  • Prior to all follow-up consultations, you may be asked to complete a short follow-up questionnaire, as well as an annual questionnaire prior to your annual visit.

 

Testing and imaging studies, including the following, should be completed and reviewed by your primary care physician and primary care medical team.

  • If not included in the recent blood testing you have obtained from your primary care provider, there will be additional blood testing performed in the beginning of your program that includes SHBG, TSH, free T3, free T4, reverse T3, FSH, and LH;
  • Within the first four months, one and possibly additional 24-hour urine hormone tests will be performed, and annually thereafter.
  • Mammogram: initial (unless you have had a recent one), then every 1 to 5 years, depending upon your risks and/or needs.
  • Bone mineral density: initial (unless you have had a recent one), then every 1 to 5 years depending on your risks and/or needs.
  • Breast thermography: if needed, for women with increased breast density, robust estrogen levels, or genetic indicators.
  • Transvaginal ultrasound: if applicable.
  • Additional referrals or evaluations may be requested by us or your primary care provider.

 

Scope of Services

Medical/health care services are limited to assessment of the appropriateness of cBHRT therapy and the determination and maintenance of an optimal menopause hormone treatment program. Our practitioners do not act as a Primary Care Physician (PCP) or as a specialist for any medical issue other than determinations regarding suitability for cBHRT. Services are offered during normal office hours. Practitioners do not provide urgent care, seek hospital admissions, provide hospital services or

give patients 24/7 access to them. Patient agrees to have a PCP or GYN actively involved with any current medical conditions or for any needed preventative care.

 

Insurance /Medicare Notice

All Services are provided to Patients on a cash basis. The monthly fee for services is not reimbursable by insurance, Medicare, and/or Medicaid. Practitioners do not participate in any health insurance program or Medicaid for the provision of these services and services are not reimbursed by Medicare. Practitioners do not accept assignment or submit insurance claims, nor can a Patient submit claims to health insurance companies, Medicare or Medicaid for the services provided under this Agreement. It is important to note that cBHRT compounds are not covered by insurance.

 

Participation in hormone therapy does call for periodic blood tests, imaging studies such as mammography, thermography, bone mineral density, and potentially other studies such as transvaginal ultrasound. Your insurance and Medicare may or may not pay for or reimburse you for these procedures. Whether or not there is potential coverage will depend on the specific test and the specifics of your policy. These tests can only be performed if ordered by a licensed provider. Whether FSA or HSA funds can be used for these services depends on your insurance company and you will be responsible for consulting with your personal health plan to verify or determine eligibility.  By signing below, you acknowledge and agree that nothing in this consent form or the Agreement with the Patient constitutes an insurance plan or a contract for health insurance and nothing in these documents is a substitute for health insurance or other health plan coverage.

 

These services are out-of-network and not covered benefits under any health plan. Payment for

services and testosterone, progesterone, DHEA and bi-est prescriptions are included in your Patient fee, and are not covered by any health plan. As a result of not being covered, these services received are  not subject to the guidelines, restrictions or policies established by health insurance companies, health maintenance  organizations, or Medicare/Medicaid. You further acknowledge and agree that the Provider ordering these services will not fulfill an insurance company’s or HMO’s requirement for an in-network primary care or specialty physician.

 

Limitations on Services

Based on the volume of services being provided, Practitioners reserve the right to impose reasonable limitations on the ability to have additional  physician access by phone or email depending on the individual needs of the Patient.  All Patients shall be provided notice of these potential limitations. . This reservation is intended to limit additional  consultations, if utilization exceeds that which is medically useful for the purpose of optimal cBHRT treatment programs.  Nothing in this agreement shall prevent medically reasonable discharge from the practice for cause. This agreement is for enhanced personal services and may not be assigned to any other person or family Patient.

 

Senior Physician

Your Practitioner may consult with a Senior physician as part of training or to receive insight into your case as a consultant. This is solely to educate or support the Practitioner and no doctor-patient relationship is created between the Senior physician and Patient based on this consultation. Patient agrees and authorizes Practitioner to release medical information and engage in case discussion with the Senior physician. Such information shall be protected and remain confidential. Patients may withdraw consent for future authorization such releases in writing at any time.

 

No Guarantee

As with any therapy, no representations or guarantees are or can be made that Patient will obtain positive results or not experience adverse reactions. The Patient participating in these services assumes all of the risk of these procedures and understands that there are risks and complications that may occur as a result of receiving these services.

 

Medical Record Release

Patient hereby agrees, and shall execute such additional documents as necessary, to allow Practitioner to share medical records with training physicians for the purpose of on-going education in our method. Such records shall be maintained in strict confidence using all appropriate security measures. A privacy policy will be provided before service begins.

 

Doctor-Patient Relationship is Solely with Assigned Medical Care Provider

Notwithstanding the foregoing, no doctor-patient relationship is created or implied between Patient and the practitioners who may be training to provide these services.

 

Intellectual Property

Copyrighted materials and intellectual property will be provided to you for your personal use only and cannot be used for unauthorized business purposes. You are not authorized to copy, share, or otherwise disseminate any materials received from this program electronically or otherwise without the prior written consent.

 

Credit Card Authorization; Collection Expenses

By agreeing to the provision of these services and providing us with valid credit card information, you are authorizing us to charge your credit card for monthly Patient Fees without any additional authorization. If you ever have reason to challenge a credit card charge, you agree not to initiate any dispute or chargeback to your account without first stating your dispute in writing to us and allowing fifteen (15) business days for us to review your complaint and participate in the dispute resolution process with you. If you cancel the credit card that you have provided to us, you agree to provide us with a replacement card and authorize us to utilize that card for your monthly fees prior to the next billing cycle.

 

If it should be necessary to pursue you for collection of any monies or fees owed to us, you agree to be responsible for any fees or costs incurred in the process of that collection, including attorney’s fees and costs and fees associated with recouping payment on fees due or on chargebacks. In the event of any change or update to your credit card, you agree to provide us with any new information prior to any subsequent charges to your credit card, and shall include all relevant information, including changes to the name on your card, your billing address and phone number. Any payments more than five days late will incur customary interest charges.

 

Term, Termination and Refund Policy

You agree that participation in this program is on a month-to-month basis and no long-term contract is either expressed or implied. Upon termination of participation by the Patient, Patient releases the Program and Medical Care Provider from any further responsibility or liability with regard to any continuing medical needs incurred after the notice of termination has been received by the Program. The Program may terminate this Agreement with the Patient if the Patient has failed to make payment to the account 30 days  after notice of delinquent payment has been  provided to the Patient.

 

Severability

If any part, term or provision of this Agreement is held by a court of competent

jurisdiction to be illegal or unenforceable, the violating portion of this agreement shall be severed from the agreement as if it never existed, but the remaining portions or provisions of this

Agreement shall not be affected. The governing law for this Agreement shall be the State of

Kansas.

 

Expected Benefits of Hormone Replacement Therapy

  • Expected benefits from these procedures include, but are not limited to, control of symptoms associated with declining hormone levels.
  • In addition, possible benefits of this therapy may help prevent, reduce, or control physical diseases and dysfunction associated with declining hormone levels, through hormonal replacement.

 

Risks and Side Effects of Hormone Replacement Therapy

Some of the following risks/adverse reactions are derived from the official Food and Drug Administration “FDA” labeling requirements for these drugs and based on therapeutic drug levels in the bloodstream. I understand that my healthcare provider may prescribe these medications at dosages designed to achieve physiologic levels of hormones considered to be beneficial.

  • I understand that the general risks of this proposed therapy may include, but are not limited to, bruising, soreness or pain, and possible infection for hormones administered by injection.
  • I further understand that there are risks (both known and unknown) to any medical procedure, treatment and therapy, and that it is not possible to guarantee or give assurance of a successful result. I acknowledge and accept these known and unknown general risks.
  • A few examples of potential therapeutic medications are listed below:

 

Testosterone

This is a prescription hormone, given by injection, ointment, or patch. The risk of testosterone replacement may include but is not limited to: stimulation of benign and malignant prostate tumors. Testosterone replacement is contraindicated in patients with known prostate cancer. It can be used to assist symptoms of sexual dysfunction in men and women and hot flashes in women. Potential benefits include improved libido, increased bone mass, and increased sense of well-being.

 

Side effects of testosterone replacement may include but are not limited to: an increase in the production of red blood cells, determined by periodic measuring of your red blood. It is not a common occurrence and generally poses no health risk. In addition, it can be corrected by donating blood or with a therapeutic phlebotomy. Male pattern baldness, gynecomastia (breast enlargement), diminished sperm production and a reduction in the size of the testicles may develop in men. Testosterone replacement may reduce insulin requirements in insulin-dependent diabetics. Older male patients may be at a slightly increased risk for the development of prostate enlargement when replacing testosterone. The concurrent use of testosterone with corticosteroids may enhance edema (fluid retention) formation. Edema may be a complication with testosterone replacement in patients with pre-existing cardiac, renal, or hepatic disease. It is not known whether testosterone replacement therapy will increase the risk for prostate cancer.

 

The most common immediate side effects (occurring in approximately no more than 6% of users) include but are not limited to: acne. application site reaction, headache, hypertension (high blood pressure), abnormal liver function tests, and non-cancerous prostate disorder. Other side effects may include greasy hair and skin, a strong body odor, and aggressiveness.

 

Estrogen

A prescription hormone, given by injection, orally, ointment or patch. Estrogen contributes to cognitive health, bone health, the function of the cardiovascular system, and other essential bodily processes. Risks associated with estrogen replacement include, but are not limited to: heart attacks, blood clot formation, gallstones, increased risk of uterine cancer and fibroid tumors. The Women’s Health Initiative study demonstrated increased risk when estrogen replacement is initiated 10 or more years after menopause.

 

Estrogen replacement is not recommended in women with a history of the following conditions: breast or uterine cancer, phlebitis and blood clots, gallbladder disease, uterine fibroma, and liver disease. Side effects may include, but are not limited to: increased body fat, fluid retention, uterine bleeding, depression, headaches, impaired glucose tolerance, and aggravation of migraines.

 

Progesterone

A prescription hormone, given orally or by transdermal cream. It can help with regulating blood pressure, mood, and sleep. Risks of progesterone and side effects may include headache, breast tenderness, upset stomach, tiredness, nipple or breast tenderness, drowsiness, fluid retention, slight dizziness, anxiety, difficult sleeping, depression, acne, rashes, hot flashes, appetite increases and weight gain.

 

Thyroid Hormone

A prescription hormone taken by mouth. Risks/adverse reactions include, but are not limited to: palpitations and rapid heart rate, heart arrhythmias, excitability, increased metabolism. Cardiac sensitivity is a contraindication to thyroid replacement therapy. Excess amounts may increase the risk for osteoporosis in some people and suppress the body’s own ability to manufacture its own thyroid hormone.

 

Side effects may include, but are not limited to: sleep disturbances, fine trembling of fingers, excessive hunger and thirst, sweating, anxiety, and headaches. Dehydroepiandrosterone-

 

DHEA

DHEA is classified as a dietary supplement, given by mouth or by transdermal cream. It may help improve mood, fatigue, and well-being. Risks of DHEA replacement include but are not limited to: worsening of certain cancers and should be avoided in men with existing prostate cancer and in women with breast cancer. DHEA replacement is not generally recommended in adults under age 35.

 

Side effects of DHEA replacement are generally dose related and may include but are not limited to: acne or oily skin, hair growth on the face, arms and legs, acne in women, and prostate enlargement in men male pattern baldness, decreased HDL cholesterol, fatigue, mood changes, weight gain and insomnia.

 

Melatonin

A non-prescription hormone given by mouth. Risks of Melatonin replacement include, but are not limited to: nighttime exacerbation of asthma. It should be used cautiously when treating some autoimmune diseases and leukemia, Hodgkin’s disease or lymphoma.

 

Side effects of Melatonin replacement may include, but are not limited to: sleep disorders, bizarre dreams, headache, fatigue, stomach discomfort, and suppression of male sex drive.

 

Pregnenolone

A non-prescription hormone given by mouth. Risks with pregnenolone replacement include, but are not limited to: exacerbation of various cancers and should be avoided in those with cancer of the prostate, breast or uterus. Very high doses may cause cardiac arrhythmias.

 

Side effects of Pregnenolone replacement may include, but are not limited to: headaches, bloating, menstrual irregularities, heartburn, acne, agitation, sedation, rash and flushing.

 

Alternatives to Hormone Replacement Therapy

I understand that there are reasonable alternatives to hormone replacement therapy, which include:

  • Leaving the hormone levels as they are and doing nothing. Risks may include, but are not limited to: experiencing symptoms of hormone deficiency, and increased risk for aging-related diseases or dysfunction resulting from declining hormone levels. This alternative may result in the need to treat diseases or dysfunction associated with declining hormone levels as they appear clinically.
  • Treating the symptoms of declining hormone levels as they develop with non-hormonal therapies. Risks may include but are not limited to: increased risk for aging-related diseases resulting from declining hormone levels.

 

My Compliance Obligation While Receiving Hormone Replacement Therapy

  • I agree to comply with the proposed treatment and therapy as prescribed, including the fact that I may be responsible for injecting, taking by mouth, applying to my skin, or administrating the hormone(s) that may be prescribed to me, and consent to periodic monitoring, when requested, which may include:
  • Laboratory monitoring of blood or urine chemistries and hormone levels
  • Physical examinations by my primary medical team
  • Regular screening evaluations
  • I agree to notify you regarding all signs or symptoms of possible reactions to my therapy.
  • I agree to comply with all other healthy lifestyle activities that have been individually recommended for me. I have completely disclosed my medical history, including prescription and non-prescription medications that I am currently taking or plan to take during my treatment, as well as any other over-the counter medications, recreational drugs or social substances, herbs, extracts, and other dietary supplements to you.
  • I agree to comply with the recommendations regarding the continuation of these preparations.
  • In the future I will receive recommendations in advance from you before stopping any prescribed therapeutic regimens or taking additional preparations that are not recommended by you.
  • I certify that I am under the care of a physician(s) for any and all other medical conditions.

 

Research and Economic Interests

I understand that the prescribing practitioner is not engaged in any personal research and has no economic interests other than the immediate care or treatment of the Patient that might affect the Practitioner’s choice of treatment or medical judgment.

 

Cancelation Policy

Your appointment time is reserved just for you. A late cancellation or missed visit leaves a hole in the nurse’s day that could have been filled by another patient.  The nurse may have already traveled to your location and your service may have already been dispensed. These efforts may result in a loss to the Company. As such, in the case of changes to your appointment or cancellation, we require that notice of change or cancellation be provided 24 hours in advance.   Patients who provide less than 24 hours’ notice, or miss their appointment, will be charged a $100 cancellation fee.

 

No Guarantee of Results; Right to Discontinue Treatment

I understand that results will vary among individuals. I understand that although I may

see a change after my first treatment, I will likely require a series of sessions to obtain

my desired outcome. The procedure and side effects have been explained to me including alternative methods, as have the advantages and disadvantages.

 

I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of the treatment. I state that I have read (or it has been read to me) and I understand this consent and I understand the information contained in it. I have had the opportunity to ask any questions about the treatment including risks or alternatives and acknowledge that all my questions about the procedure have been answered in a satisfactory manner. I understand that I have the right to discontinue treatment at any time.

 

Patient Certifications

I certify that I have been given the opportunity to ask any and all questions I have concerning the proposed treatment.  I received all requested information and all questions were answered. I fully understand that I have the right to not consent to hormone replacement therapy. I believe I have adequate knowledge upon which to base an informed consent.

By my signature below, I attest to reading and fully understanding this form and the contents and clinical meanings of such and have discussed these procedures with my healthcare provider and consent to this treatment. I hereby authorize this proposed long-term treatment. I have been given a copy of this consent form, and I fully understand the represented meanings of terms used herein, the risks, implications and realistic expectations of these procedures.

I have discussed my integrative approach to treatment and understand that it involves the use of Bio-identical (natural) Hormone Replacement Therapy, alongside supplements and vitamins unique to the patient’s individual needs.

I have been fully informed, and I am satisfied with my understanding, that this treatment may be viewed by the medical community as new, controversial, and unnecessary by the Food and Drug Administration.

I understand that my healthcare provider cannot guarantee any health benefits or that there will be no harm from the use of hormone replacement therapy.

I have discussed the cardiovascular risks, breast and/or endometrial cancer risks associated with the use of hormones.  I have been provided the opportunity to discuss any questions or concerns regarding risks of BHRT before being administered the prescription. It has been explained to me, and I understand that, as the Patient, it is my responsibility to keep up-to-date with their regular breast exams as recommended by my doctor, and to report any adverse side-effects.

 

Statement of Person Giving Informed Consent

I have read this consent form and all accompanying documents and understand the information contained in it. I understand the benefits and risks and have had the opportunity to have all my questions answered to my satisfaction prior to participation. I am aware that other unforeseeable complications could occur. I do not expect the provider(s) to anticipate and or explain all risks or possible complications to me and I understand that the ability of Liquid to properly advise me may be limited to the accuracy and honesty of the information that I provide. I rely on the provider(s) to exercise reasonable judgment during the course of treatment with regards to my procedure. My signature on this form affirms that I give my consent to IV nutrient, intramuscular injection, lab testing or other medical services.

 

Release of Medical Information

I hereby authorize Liquid to disclose my medical records to Liquid staff or contracted workers, to EMS, my spouse, and emergency contact. I also authorize Liquid to discuss my care and share my medical information for the purposes of monitoring, quality control or safety concerns.

 

Age Consent

I hereby acknowledge that I am 18 years of age or older and certify that I am authorized and able to make healthcare decisions and have full knowledge of the services being provided, including potential risks and side effects. I hereby agree that no guarantees have been made to me regarding the outcome or ultimate effect of the services that I receive.

 

I hereby give consent to treat.

I have received knowledge of the services being provided, including potential risks and side effects. I hereby agree that no guarantees have been made to me as to the effect services. and I hereby give consent to treat.

 

Overall Informed Consent for Treatment

Liquid provides multiple medical services, including, but not limited to: intravenous and injection therapies, labs, weight management, telehealth, hormone therapies, and aesthetics. A trained Liquid nurse, nurse practitioner or physician administers the services under the direction of a licensed physician. You have the right to be fully informed of the detailed process of the services, as well as the benefits and any potential risks of the services and may refuse to proceed with the service at any time during the process.

 

Overall Informed Consent and Agreement of Services

My Consent for Nutrient Infusion, Intramuscular Injections, Lab Testing, Aesthetic Procedures, Medical Weight Management, Hormones, Telehealth and other services provided by Liquid are  voluntary. My request for nutrient infusion, intramuscular injections, lab testing, aesthetic procedures, medical weight management, hormones, telehealth and other services provided by Liquid as described above is entirely voluntary and I have not been offered any inducement to participate or provide this consent. I understand that I may refuse to participate in this therapy at any time during this process. I also understand and commit to always working back with my primary care providers including them on all care, treatments, therapy and information provided by Liquid.

 

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