Medical Spa Intake

Protected Health Information/PHI:

Arctic Medical Center takes pride in protecting your information. If you would like our office to discuss your health information with anyone, please indicate this below.

This office is required to notify you in writing, that by law, we must maintain the privacy and confidentiality of your Personal Health Information. In addition, we must provide you with written notice concerning your rights to gain access to your health information, and the potential circumstances under which, by law, or as dictated by our office policy, we are permitted to disclose information about you to a third party without your authorization. Below is a brief summary of these circumstances.

1. Treatment purposes - discussion with other health care providers involved in your care.
2. Inadvertent disclosures - open treating area mean open discussion. If you need to speak privately to the doctor, please let our staff know so we can place you in a private consultation room.
3. For payment purposes - to obtain payment from your insurance company or any other collateral source.
4. For workers compensation purposes - to process a claim or aid in investigation.
5. Emergency - in the event of a medical emergency we may notify a family member.
6. For Public Health and Safety - to prevent or lessen a serious or eminent threat to the health or safety of a person or general public.
7. To Government Agencies or Law Enforcement - to identify or locate a suspect, fugitive, material witness or missing person.
8. For military, national security, prisoner, and government benefits purposes.
9. Deceased persons - discussion with coroners and medical examiners in the event of a patient’s death.
10. Telephone calls or emails and appointment reminders - we may call your home and leave messages regarding a missed appointment or appraise you of changes in practice hours or upcoming events.
11. Change of ownership- in the event this practice is sold, the new owners would have access to your PHI.

 

YOUR RIGHTS:

1. To receive an accounting of disclosures.
2. To receive a paper copy of the comprehensive “Detail” Privacy Notice.
3. To request mailings to an address different than residence.
4. To request Restrictions on certain uses and disclosures and with whom we release information to, although we are not required to comply. If, however, we agree, the restriction will be in place until written notice of your intent to remove the restriction.
5. To inspect your records and receive one copy of your records at no charge, with notice in advance.
6. To request amendments to information. However, like restrictions, we are not required to agree to them.
7. To obtain one copy of your records at no charge, when timely notice is provided (72 hours). X-rays are original records, and you are therefore not entitled to them. If you would like us to outsource them to an imaging center, to have copies made, we will be happy to accommodate you. However, you will be responsible for this cost.

I have received a copy of the Patient Privacy Notice. I understand my rights as well as the practice’s duty to protect my health information and have conveyed my understanding of these rights and duties to the doctor. I further understand that this office reserves the right to amend this “Notice of Privacy Practice” at a time in the future and will make the new provisions effective for all information that it maintains past and present.

I am aware that a more comprehensive version of this “Notice” is available to me. At this time, I do not have any questions regarding my rights or any of the information I have received.

Please answer the following questions:

I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of the staff responsible for any errors or omission that I may have made in the completion of this form.

A. CONSENT FOR PRIAPUS SHOT®/P SHOT® PROCEDURE

I have received information about my condition, the proposed treatment, alternatives, and related risks. This form contains a brief summary of this information. I have received an explanation of any unfamiliar terms and have been offered the opportunity to ask questions. Ihave not received any promise, guarantee or warranty that my undergoing the Priapus Shot®/P Shot® procedure will achieve a particular result.

I fully understand that individual results do vary, and that Erika Dominick CRNP assumes no responsibility for failure to achieve a desired result. I understand I may refuse consent and I GIVE MY INFORMED AND VOLUNTARY CONSENT to the proposed procedures and the other matters shown below. I also consent to the performance of any additional procedures determined in the course of a procedure to be in my best interests and where delay might impair my health.

1. I authorize Erika Dominick CRNP to treat my condition, including performing further diagnosis and the procedures described below, and taking any needed photographs.
2. I understand the proposed Priapus Shot®/P Shot® procedure(s) to be: a procedure for rejuvenating, enlarging and strengthening the penis, using blood-derived growth factors (plateletrich fibrin matrix (PRFM), platelet-rich plasma (PRP) injections.
3. I understand the risks associated with the proposed procedure(s) to be: possible bleeding, infections, urinary retention, no effect at all, allergic reactions, mental preoccupation of the penis, alteration of the function of the penis, sexual function alteration, hematoma, increased/worsening nocturia (waking up several times at night to urinate), change in urinary stream, need for subsequent surgery, alteration of penile sensations, scar formation (penile), local tissue infarction and necrosis, fatigue, alteration of bladder dynamics, post-operative pain, prolonged pain, intractable pain, alteration of the male sexual response cycle, failed procedure, varied results, psychological alterations. relationship problems, sex life alteration, possible hospitalization for treatment of complications, lidocaine toxicity, anesthesia reaction, embolism, depression, reactions to medications including anaphylaxis, nerve damage, permanent numbness, slow healing, swelling, sexual dysfunction, allergy, nodule formation.
4. I also understand that there may be other RISKS OR COMPLICATIONS, OR SERIOUS INJURY from both known and unknown causes. I am aware that the practice of medicine and surgery is not an exact science and I acknowledge that no guarantees have been made to me concerning the risks of the procedure.
5. I understand that the use of PRP in this procedure is an “off-label” use, and no promise or representation guarantee or warranty regarding its use, benefit or other quality is made. No representations that the use of this product and this procedure is approved by the FDA or any other agency of the federal or state government is made. I understand the alternatives to the proposed procedures and the related risks to be: do nothing.
   
   

B. CONSENT FOR ANESTHESIA
When local anesthesia and or sedation is used by the provider: I consent to the administration of such local anesthetics as may be considered necessary by the provider in charge of my care. I understand the risk(s) of local anesthesia include but are not limited to: local discomfort, swelling, bruising, allergic reactions to medications, and seizures from lidocaine.

C. PATIENT CERTIFICATION:
I have received information about my condition, the proposed treatment, alternative(s), and related risk(s). This form contains a summary of this information. I have received an explanation of any unfamiliar terms and have been offered the opportunity to ask questions. I understand I may refuse consent at any time. I have read and understand this form, and I give my informed and voluntary consent to the proposed procedure(s). I also consent to the performance of any additional procedure(s) determined by my provider during the procedure(s). By signing below, I state that I am 18 years of age or older, or otherwise authorized to consent.

D. PROVIDER ATTESTATION
I have explained the procedure(s), alternative(s) and risk(s) to the person or persons whose signature is affixed above. The patient has verbally communicated to me that they understand the consents of this form.

E. INTERPRETER ATTESTATION (when applicable)
I have provided translation to the person(s) whose signature(s) is affixed above.