Telemedicine Informed Consent (Telemedicine only)
Please read and E-Sign the form at the bottom of the page and click SUBMIT to complete and send us the form.
1. I understand that my health care provider wishes me to engage in a telemedicine consultation.
2. I understand that the telehealth consultation will not be the same as a direct patient/health care provider visit due to the fact that I will not be in the same room as my health care provider.
3. I understand there are potential risks to this technology, including interruptions,unauthorized access and technical difficulties. I understand that my health care provider or I can discontinue the telemedicine consult/visit if it is felt that the technological connections are not adequate for the situation.
4. I understand that my healthcare information may be shared with other individuals for scheduling and billing purposes. Others may also be present during the consultation other than my healthcare provider and consulting health care provider in order to facilitate the consultation, scheduling or operation of equipment. The above mentioned people will all maintain confidentiality of the information obtained. I further understand that I will be informed of their presence in the consultation and thus will have the right to request the following: (1) omit specific details of my medical history/physical examination that are personally sensitive to me; (2) ask non‐medical personnel to leave the telemedicine examination room: and or (3) terminate the consultation at any time.
5. I understand the alternatives to a telemedicine consultation, and in choosing to participate in a telemedicine consultation. I understand that some parts of the exam involving physical tests may be conducted by individuals at my location at the direction of the consulting health care provider.
6. I have had a direct conversation with my doctor, during which I had the opportunity to ask questions in regard to this procedure/protocol. My questions have been answered and the risks, benefits and any practical alternatives have been discussed with me in a language in which I understand.
CLINIC CONSULTANT CONTACT Your NovaGenix “Consultant” will be your immediate contact for questions, problems or concerns. We recommend storing our contact information into your cell phone for future convenience. Our number is 561-277-8260
LABS· NovaGenix staff will accept cash, check or Credit Card payment for lab work. Please provide NovaGenix with your blood work,diagnostic procedures or medical records that can better help us care for you.
PRESCRIPTION MEDICATION· Prescriptions are sent to the pharmacy filled and shipped – most deliveries take 1-2 days. You may/will need to sign for the delivery. Please ensure your address is correct. No deliveries to P.O. boxes. Some medications need to be REFRIGERATED after delivery– read package instructions carefully. You will receive your medication.
If you have any questions about how/when to take medication, how to mix medication, how to give yourself an injection – WE CAN HELP! Call/Text us, as we are here to help you. Take your medications as prescribed and follow the physician’s recommendations and instructions.· Report any adverse reactions and monitor your symptoms. What did you feel like before? Is that feeling changing? How do you feel now? Better? Worse? Please let us know. Please continue to see your primary care physician for continuing medical care. NovaGenix provides anti-aging and hormone replacement therapies and is NOT Primary Care Practitioner. Our goal is to optimize your health.If you have any questions,please call your NovaGenix Consultant at 561-277-8260.
Future Lab Work NovaGenix,LLC will provide future blood/lab work for recurring monthly patients afterthey start treatment at 8-10 weeks and once again in 12 months after starting therapy.
If patients would like additional tests, it may be at an additional cost to the patient.
Medication Refills: Contact your NovaGenix Consultant two (2) weeks before you need medication refilled to prevent any interruption of treatment.
Consent & Waiver ALL Patients
I have been explained to, and understand in their entirety all possible side effectsof possible treatments involving Hormone Replacement Therapy (HRT), including but not limited to: Human Chorionic Gonadotropin (HCG), Testosterone, Estrogen, progesterone, anastozole, etc. I have been also explained to, and understand in their entirety all possible side effects of WeightLoss Programs, which may include but not be limited to phentermine and vitamins D and B12, as well as Erectile Dysfunction medications, sildenafil citrate, tadalafil,tri-mix, quadmix or Platelet Rich Plasma therapy, Stem Cell treatments and anyother treatments/medication that may be discussed with the doctor.
I specifically hold harmless and waive any and all claims or defenses against NovaGenix,LLC and its employees, agents, contractors, contracting physicians, officers, directors, shareholders and contracting medical laboratories for any harm or injury I may sustain resulting from any act or omission of said treatingmedical doctor or other party.
I also hold harmless and waive any and all claims and defenses against NovaGenix,LLC and its employees, agents, contractors, contracting physicians, officers,directors, shareholders for any harm or possible injury I sustain as a resultof my failure to comply with the method of treatment and dosage schedule prescribed by said doctor. Iagree to immediately cease any medical treatment prescribed by said doctor in the event of any adverse response or side effects arising from the prescribedtreatment, and provide immediate written notice to NovaGenix, LLC.
I further agree to comply with prescribing instructions for use of allmedications. I,the undersigned patient, understand that the practice of medicine is not anexact science and that the diagnosis and treatment of my condition may involvecertain risks or the possibility of injury. I acknowledge that no promises,assurances, or guarantees have been made to me as to the result of diagnostic testing, analysis of test results, examination and medical history, orprescribed treatment protocols by NovaGenix, LLC or its contracting physicians.
I understand that the hormone blood level objective sought to result from myhormone replacement therapy, as prescribed by my treating medical doctor may be the highest level of a standard reference range for my sex, age, or even a higher hormone blood level normally found in a person younger than myself.
I understand that hormone replacement therapy for the purpose of elevating my hormone levels to the highest level of standard reference range for my age and sex, or above such range to the level of a younger person, is experimental and may not render any benefits, but may result in unknown adverse results.
I have been made aware of the nature, risk, possible alternatives or treatments,possible consequences, and possible complications involved in my treatment. Iunderstand that recombinant Human Growth Hormone replacement for adults involves the use of a medical drug approved for one purpose for a new anddifferent purpose in an effort to obtain a sought objective of medical treatment. Nevertheless,
I consent to care and treatment and I execute this form with complete informed understandingand for the purpose of authorizing NovaGenix, LLC and its physicians to administer to me for the relief of my body ailments, and to enhance my physical condition and health. I understand that the methods of medical treatment offered or provided are not accompanied by any claims, guarantees, or promises. I understand that Human Chorionic Gonadotropin (HCG), involves the use of a medical drug approved for one purpose for a new and different purpose in an effort to obtain a sought objective of medical treatment. Nevertheless, I consent to care and treatmentand I execute this form with complete informed understanding and for the purpose of authorizing NovaGenix,LLC and its contracting physicians to administer such treatments. I understand that the methods of any of NovaGenix, LLC medical treatments offered or provided, including Stem cell, PRP, hormone therapy, ED treatments and Weightloss services are not accompanied by any claims, guarantees, or promises andthat all sales are final.
I agree to present my photo identification prior to or before the consultation or at any time my blood is drawn pursuant to NovaGenix, LLC test requisitions. I understand that there are no refunds for prescription medications as per State and Federal Law. I also understand the medicine dispensed to me is for mypersonal use only and I will not sell or share my prescribed medicine with others. Iunderstand that medical information revealed by me may be used for continued medical research purposes, but that I will not be personally identified at anytime.
I understand that a prescribed drug ordered for me from NovaGenix, LLC may bedispensed directly to me by a pharmacy in my country. Consent for Medical Treatment (BHRT,PRP, Stem Cell Therapy, ED/PE, Weight Loss)
I understand that I have a condition that requires medical treatment.Iauthorize NovaGenix, LLC and its physicians to determine what kind of treatmentis to be given and to perform such procedures as he/she may deem necessary, in his/her professional judgment, in an effort to preserve my health. Additionally,
I authorize the personnel of NovaGenix, LLC to administer the therapy which my doctor may order. I fully understand that the medical tests or treatments may involve certain unavoidable risks, which have been fully explained to me. I understand that the practice of medicine and surgery are not exact sciences and acknowledge that no guarantee or assurance has been made to me as to the results of treatment or examinations.
Cancellation of services policy:
All Sales are final, as we cannot accept prescription medications after they have been prescribed, or refund for procedures after they have been performed by the physician. Patients may cancel recurring monthly services at any time with 30 Day’s notice or if the ballance of the medication/treatments have been paid in full. (An email or phone call will suffice for notice of cancellation). All patients who begin hormone replacement therapy will be billed automaticaly on a monthly basis and medications/supplies shipped by the pharmacy every other month unless other arrangement have been made with NovaGenix and the patient.unless other billing dates/arrangements are made with NovaGenix.
PERSONAL GUARANTEE: I hereby irrevocably and unconditionally guarantee to NovaGenix, LLC the timely payment and performance of all of my liabilities and obligations pursuant to this agreement. Should I fail to pay charges when due, then after notice by NovaGenix, LLC, I shall immediately cure my nonpayment in the same manner and as completely as I am obligated to do. My liability is direct, immediate, absolute, continuing, unconditional and unlimited. NovaGenix, LLC shall not be required to pursue any remedies it may have against me as a condition to enforcement of this Guaranty, nor shall it be discharged or released by reason of the discharge or release of me for any reasons, including a discharge in bankruptcy, receivership or other proceedings.
Credit Card Authorization Form
In an effort to better serve you and simplify your billing experience, NovaGenix, LLC requires credit card preauthorization for recurring monthly charges for patients who agree to monthly treatment programs. Charge card information is filed with your confidential information and kept secure. Accounts on file will be charged automatically each month upon the due date. We appreciate your prompt payment.
I hereby authorize NovaGenix, LLC. to automatically charge my account either each month for all fees due for a recurring fee or for a one time charge for services. I understand that my card will be charged on a monthly basis or as needed for labs or additional medical services or medications. I understand I may cancel recurring monthly services at any time with 30 Day’s notice (email or phone call will suffice).
If, after a payment by credit card, you later dispute the charges, unless prohibited by law, you agree not to cancel, revoke, charge back, or dispute any previously entered charge on your credit card. If you do so, and it is later determined that the charge was properly authorized and medication/treatment/services have been rendered and/or received, you agree to pay all out of pocket fees and costs incurred by NovaGenix, LLC as a result of the improper cancellation, revocation, charge back, or dispute including legal fee's.
*I certify that I have read this form in its entirety and have had it explained to me uponrequest, and I certify that I fully understand its contents in their entirety including billing and cancellation policies.
*Electronic Signature Agreement. By typing your name below, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement and that all information provided is true.