________ If you are late or miss your appointment, you may be subject to a $50 fee.
________Services must be paid for at the time of service.
________Health insurance typically does not cover services provided at (Bottumzup Health and Wellness). If you want to seek insurance reimbursement, we would be happy to provide you itemized invoices that you can submit to your insurance company.
_______ I agree that if I am having any side effects or become sick, that I will follow up with my primary care provider or go to an urgent care or emergency department.
________I acknowledge that (Bottumzup Health and Wellness) and (Karen Molina Melendez) are not my primary care provider. I agree that I will continue with routine care through my primary care provider and notify them of treatments prescribed and performed at (Bottumzup Health and Wellness).
________I understand that there are no refunds for services or products rendered.
________I understand that having an appointment with (Bottumzup Health and Wellness) does not necessarily entitle me to having an IV infusion or injection procedure performed. Every individual is different, and it is at the medical providers discretion to issue treatment.
________I acknowledge that I have been advised of the risks and benefits of treatment. I also acknowledge that I have been advised of possible complications and side effects. I understand the risks, benefits, complications, and side effects of treatment.
________I am voluntarily requesting treatment with (Bottumzup Health and Wellness) and (Karen Molina Melendez) in regard to IV infusion therapy and injection therapy as determined by a mutual decision between myself and the medical provider even if it is not considered a medical necessity.
________I do not hold any medical practitioner of (Bottumzup Health and Wellness) responsible for performing age-related preventive care. I agree that I will follow up with my primary care provider to obtain these screenings and I hold (Bottumzup Health and Wellness) and (MEDICAL PROVIDER) harmless if an adverse event occurs during my treatment.
*I have read, understand, and agree to all of the above statements. I have initialed and signed below to confirm to agreement of Patient Clinic Policies