Consents and Authorizations
Consents and Authorizations
I hereby authorize Quintessence Health and Wellness to obtain from any source and examine and use, or discuss and disclose and provide any information necessary regarding the patient with health care practitioners involved in the care of the patient. These communications of information may include unencrypted electronic communications. This authorization to obtain and release information is valid until revoked. The undersigned may revoke this consent in writing at any time, except with regard to information that has already been shared or disclosures that have already been made in reliance on such consent.
Electronic Communications Authorization
I hereby authorize Quintessence Health and Wellness to communicate with me using electronic communications including email, text messages, and voicemail. I may be contacted using the numbers or addresses that I have provided to Quintessence Health and Wellness or that I have used to initiate contact with QH&W. These communications may include appointment information, protected health information and confidential information. I understand that these electronic communications are not encrypted.
Acknowledgment of Review of Notice of Privacy Practices
I have the legal right to consent to medical and infusion treatment because I am the patient or I am the patient representative. I voluntarily authorize and consent to the medical care, treatment, and diagnostic tests that the providers at Quintessence Health and Wellness and their designees are necessary. I understand that by signing this form, I am giving permission to the doctors, nurses, nurse practitioners, and other health care providers of Quintessence Health and Wellness to provide treatment as long as a physician/patient relationship exists, or until I withdraw my consent.
Agreement to Pay
I understand that I am directly responsible for all charges incurred for medical services for the patient.
I have the legal right to consent to medical and infusion treatment because I am the patient or I am the patient representative. I consent to the procedure(s) or treatment(s) as outlined below to be performed by the medical provider(s) of Quintessence Health and Wellness, their staff, associates, assistants and designees to whom the physician(s) performing the procedure may assign responsibilities.
The proposed procedure(s) or treatment(s) is: KETAMINE IV INFUSION
The procedure(s) or treatment(s) has been explained to me in terms that I understand. The explanation included:
The nature and extent of the procedure to be performed.
- The most frequently occurring risks of the procedure involved, and those risks which are unlikely to occur but which may involve serious consequences.
- The benefits of the procedure.
- The estimated period of incapacity.
- The risks and benefits of any reasonable alternatives to this procedure including having no treatment at all.
I understand that:
- The drugs used and rates of infusion and duration of infusion will vary from patient to patient depending on the appropriate treatment plan for each patient. For a 40 minute infusion there will be a recovery period in the office of approximately 30 minutes. For an infusion with a duration of up to two hours there will be a recovery period of up to approximately 1 hour.
- The use of Ketamine for the treatment of Depression and some other conditions are considered investigational by the Food and Drug Administration.
- Ketamine is considered useful for the treatment of Depression and some other conditions. Effects typically begin within several hours of treatment. It is also possible to have no positive effect from Ketamine infusions.
- Side effects of Ketamine may include dizziness, bad dreams, perceptual disturbances, confusion, elevations in blood pressure, euphoria, dizziness, increased libido and nausea. These side effects typically disappear at the end of the infusion.
- Ketamine is an anesthetic agents and the administration of these drugs is considered anesthesia.
- Complications with anesthesia can occur and include: drug reaction, the possibility of infection, bleeding or injury to blood vessels at the intravenous site. More severe complications could include depression of respiration and heart problems that could lead to serious consequences, including loss of life.
I agree to the Following:
- If applicable, I affirm that I am not pregnant or breastfeeding and that I have no intent of becoming pregnant in the near future. I fully understand the potential for risks to a developing embryo and fetus.
- I agree not to drive a car, operate machinery or make any legal decision within 12 hours after the procedure(s) or treatment(s).
- I am willing to keep myself safe during treatment and in between ketamine infusions.
- I agree to contact 911 in the event that I become suicidal or for any other life-threatening emergency following the procedure(s) or treatment(s).
- I agree to follow up with my referring physician or another licensed medical professional following the course of treatment, and at any time if my conditions worsens.
- I was given the opportunity to ask any questions I have regarding the procedure(s) or treatment(s) and I have had those questions answered to my satisfaction.
- I understand that I may consult or could have consulted with another physician about this procedure(s) or treatment(s).
- I understand that this procedure(s) or treatment(s) is completely voluntary and that I may pursue alternative treatments or no treatment at all for my condition(s).
- I understand that I have the right to refuse this procedure(s) or treatment(s) at any time prior to or during its performance.
- I authorize the physician to perform such additional procedures or treatments, including administering additional medications, which in his/her judgment are incidentally necessary or appropriate to carry out my care.
- If any unforeseen condition arises during this procedure(s) or treatment(s) which requires transportation to a hospital, additional procedures, operation or medication including anesthesia and blood transfusions, I further request and authorize the physician to do whatever he/she deems advisable on my behalf.
- I am aware that the practice of medicine is not an exact science, and I acknowledge that no guarantees or assurances have been made to me concerning the results of this procedure(s).
- I acknowledge that I have read (or had read to me) and fully understand the information on this form. Furthermore, I certify that all my questions and concerns regarding the procedure(s) or treatment(s), its attendant risks, benefits and alternatives have been explained to my satisfaction. I hereby authorize the physician to perform the above discussed procedure(s) or treatment(s).