Patient Authorization Agreement TERMS AND CONDITION
Your health is a very important personal issue, and we understand that the confidentiality of your information is of the highest priority and of utmost importance. To protect your privacy, we have implemented and will follow specific security protocols and processes on every matter that is related to your files and information. We use the highest level of individual customer, electronic transfer, and internet security features provided by Jotforms and Practice Fusion's electronic health record system. They are specifically designed to guarantee your privacy and security to the very best of our ability. Our company policy is to not allow any unauthorized party access to any part of your personal financial or medical information without your written instruction.
ONLINE ORDERS
Nothing contained in this Website or in printed materials shall constitute an offer by Native Healthcare Center dba JennyK Weightloss, its officers, employees, or affiliates to buy or sell products or services to you. No agreement to sell products or services shall be formed until you place an order. Then, Native Healthcare Center and its affiliates approve it in the manner outlined in Native Healthcare Center's specific ordering instructions. The terms of such agreement shall be those of Native Healthcare Center's established procedures or any such of our affiliate's standard terms and conditions. All product requests or orders are subject to all applicable laws of the State of Texas.
PATIENT AUTHORIZATION AND CONSENT
In consideration of instructions from Native Healthcare Center dba Nativewellspa and Weightloss Centre, hereinafter referred to as "nurse practitioner" providing the undersigned patient, hereinafter referred to as ("Patient") with medical management, administrative, or referral services, the Patient acknowledges and agrees to the following terms and conditions contained in this Patient Authorization Agreement ("Agreement") and supersedes all other instructions written or oral received from Native Healthcare Center dba Jenny K Weightloss. With this agreement, the Patient also submits an accurately completed Medical History Form, referred to as ("MHF"). The patient agrees to respond truthfully, accurately, and entirely in completing the MHF or with any agent provided by Native Healthcare Center dba JennyK Weightloss to assist in completing the form and acknowledges that failure to provide truthful, accurate, and complete information on the MHF or to the coordinator, the physicians, nurse practitioners, nurses or staff referred by Native Healthcare Center dba JennyK Weightloss could result in inappropriate treatment. Neither Native Healthcare Center nor Jenny K Weightloss is the patient primary care provider. The patient should always consult with PCP before starting a new medication.
The patient authorizes the Native Healthcare Center dba JennyK Weightloss, its staff, agents, or coordinators to obtain medical laboratories or diagnostic testing on my behalf when required by nurse practitioners, physicians, and dispensing pharmacies. In addition, the Patient authorizes and instructs Nurse Practitioners, Physicians hereinafter referred to as ("Physicians or Advanced Practice Providers"), and any dispensing pharmacies obtained on my behalf to provide medical care and prescribed pharmaceuticals if necessary, are based on the MHF, laboratory diagnostic tests, and other information submitted to Native Healthcare Center dba JennyK Weightloss or its Nurse Practitioner, Physician under this agreement. The patient agrees to present photo identification upon any blood testing pursuant to a healthcare provider test requisition.
Patient acknowledges that therapies, laboratory, and diagnostic testing services supplied or obtained by Native Healthcare Center dba JennyK Weightloss and medical services provided to me by Nurse Practitioners, Physicians, or pharmacies are not covered or reimbursed by insurance.
Patient covenants and agrees to comply with the method of instructions, treatment, and dosage schedules prescribed by the Nurse Practitioner or Physician, The Patient further agrees to immediately cease any medical treatment prescribed by the Nurse Practitioner or Physician in the event of any adverse reaction or side effect arising from or believed to arise from the prescribed treatment and to immediately provide Nurse Practitioner, Physician, and Patients Personal Care Physician with a written notice via e-mail to Physician at nativewellspa@gmail.com or by telephone to 713 309-6417 of any such adverse reaction or side effect.
I further acknowledge and agree that Native Healthcare Center is not liable for any negligent act or omission of the Physician. The patient acknowledges that diagnosis and treatment may involve risk of injury and that Native Healthcare Center dba Native Wellspa & Weightloss Centre and Nurse Practitioner, or Physician have made no guarantees or warranties for the above-described diagnostic testing, analysis of test results, or examination of medical history.
Nonetheless, the Patient freely consents to such care and treatment and executes this Agreement with a complete, informed understanding of the SEMAGLUTIDE Assisted Diet protocols to authorize the Nurse Practitioner or physician to administer such treatment to attempt to enhance the Patient's physical condition and health based on Patients MHF. The patient further acknowledges that any claims, guarantees, promises, or warranties do not accompany the methods of medical treatment offered by the Nurse Practitioner or Physician.
It is fully agreed and understood by the patient that personal office use or prescription products purchased through or obtained on my behalf require medical approval or prescription and as such are NOT returnable or refundable under any circumstances under both Federal and/or State laws. It is unlawful for a pharmacy or clinic to accept the return of office use or prescription medications once they have left the control of the clinic or pharmacy or been utilized.
The patient is freely seeking medical consultation via the Internet, phone, or direct contact and acknowledges, requests, and consents to a Nurse Practitioner or Physician reviewing their medical history without having the opportunity to conduct an in-person physical examination. The patient solicits Native Healthcare Center dba JennyK Weightloss to order any specific office use or prescription medication to take part in the Semaglutide, or any other weight loss program off label. Further, the Patient agrees that Physician's consultations, diagnoses, will be deemed to have occurred in Texas, and with the legal rules for Telemedicine in Texas
The patient represents that he or she is under the care of a Primary Care Physician (PCP) and that the Nurse Practitioner or Physician will not rely on or substitute the advice of any physician should that advice conflict with the advice given by Patient Primary Care Physician. Before taking any medication patient agrees to have or to have had a physical examination by their (PCP). Patient agrees to notify his or her (PCP) and advise such (PCP) that they or intends to begin the Semaglutide, or any other weight loss program offered by Native Healthcare Center dba Native Wellspa & Weightloss Centre.
The patient acknowledges that under Texas law, nurse practitioners or physicians are generally required to carry medical malpractice insurance or otherwise demonstrate financial responsibility to cover potential claims for medical malpractice.
Patient acknowledges and agrees that Native Healthcare Center is not responsible for the negligent or intentional acts or omissions of any health care provider, Physician, or supplier that Patient is referred to or for any action or inaction taken by Patient and that the total liability of Native Healthcare Center, its officers, directors, employees, agents, and stockholders is limited to the purchase price of any products through Native Healthcare Center, Nurse Practitioners, Physicians or Pharmacies, and that Native Healthcare Center and Nurse Practitioners, Physicians will not be liable for any direct, indirect, special, accidental, consequential, or punitive damages.
During the Patients relationship with Nurse Practitioners, Physicians, or agents, the Patient will receive a range of proprietary business information including, confidential disclosures, trade secrets, business practices, and Native Healthcare Centers dba JennyK Weightloss , its associates and suppliers ("Confidential Information"). No matter how received by the Patient during the parties' relationship, the Patient agrees that Confidential Information is confidential, proprietary, and uniquely valuable to Native Healthcare Center dba Native Wellspa & Weightloss Centre and could gravely affect the conduct of the business of Native Healthcare Center dba JennyK Weightloss and Native Healthcare Center dba JennyK Weightloss goodwill. Patient agrees not to disclose, divulge or communicate, in any fashion, form, or manner, either directly or indirectly, any Confidential Information or take any action that may result in the disclosure of Confidential Information to any third-party person, firm, or business.
The patient agrees that the amount of Native Healthcare Center actual damages in such circumstances would be difficult, if not impossible, to determine with accuracy, but would be substantial in any event, and the Patient agrees that such damages are a penalty.
Based on the above understanding and my signature below, the Patient agrees to release Native Healthcare Center, its officers, directors, employees, agents, and shareholders, the Nurse Practitioner, and the physician from any and all liability associated with or arising from the Physician's consultation or from the medical, physical, behavioral or other effects of any medication or treatment that may be ordered, prescribed or purchased as a result of the Physician's consultation.
This Agreement shall be governed, construed, and enforced in accordance with the laws of the State of Texas, applicable to agreements made and to be made and to be performed entirely within such State, without regard to principles of conflict of laws. Any disputes arising out of, in connection with, or with respect to this Agreement, shall be adjudicated in a court of competent jurisdiction sitting in Harris County, Houston, Texas, and nowhere else. Patient hereby irrevocably submits to the jurisdiction of such court for the purposes of any suit, civil action, or other proceeding arising out of, in connection with, or with respect to this Agreement. In the event of any litigation arising out of this Agreement, the prevailing party shall be entitled to recover all expenses and costs incurred, including reasonable attorneys' fees and legal assistants' fees.
This Agreement contains the entire understanding of the parties and supersedes all prior and contemporaneous agreements and discussions between the parties. All representations or agreements by any agent or representative of either party not contained in this Agreement shall be null, void, and of no effect.
If any provision of this Agreement or the application thereof to any person or circumstances is invalid or unenforceable in any jurisdiction, the remainder hereof, and all application of such provision to such person or circumstances in any other jurisdiction, shall not be affected thereby, and to this end, the provisions of this Agreement shall be severable.
Patient covenants and agrees to indemnify, defend, protect, and hold harmless the Nurse Practitioner, Physician, and their respective officers, directors, employees, stockholders, assigns, successors, and affiliates hereinafter referred to as ("Indemnified Parties") against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceedings, investigation, demands, judgments, settlement payments, deficiencies, penalties, fines, interest and costs, and expenses suffered, sustained, incurred or paired by the Indemnified Parties in connection with, resulting from, or arising out of, any acts, directly or indirectly, by Native Healthcare Center dba Jenny K Weightloss their staff and/or Nurse Practitioner, Physician's rendering medical care services, advice and/or treatment resulting from Patient's acts or omissions or failure to disclose all relevant information regarding Patient's medical and physical condition. Native Healthcare Center dba JennyK Weightloss Nurse Practitioner and Physician are released from any responsibility to the patient that results from acts, omissions, or disclosure failures by the Patient as mentioned above.
The patient is aware of potential side effects associated with the above-described diet treatment, accepts all risks involved in taking medication and the very low-calorie diet protocols, and will not seek damages from the Indemnified Parties of this Agreement.
I the undersigned Patient have read and clearly understand and agree to all the above Terms and Conditions of this Agreement from Native Healthcare Center dba JennyK Weightloss