This consent form is to inform you about the services provided by Checkmate Technology LLC (“Checkmate”) and to obtain your consent for receiving medical care from Kings Medical PC, a licensed medical provider affiliated with us.
Service Authorization
Provider Affiliation: You understand that Checkmate collaborates with a network of third-party medical professionals who are licensed and qualified to deliver comprehensive medical services. These individuals may include Emergency Medical Technicians (EMTs), Registered Nurses (RNs), Nurse Practitioners (NPs), Physician Assistants (PAs), Certified Registered Nurse Anesthetists (CRNAs), Doctors of Osteopathy (DOs), Medical Doctors (MDs), and other healthcare specialists. Although these providers are affiliated with Checkmate, they operate as independent contractors and are not direct employees of Checkmate.
Consent for Treatment: By agreeing to this consent, you authorize the medical professionals sourced by Checkmate to provide medical care and services. This care may include but is not limited to diagnostic evaluations, physical examinations, medical treatments, and any other services deemed necessary for your health condition.
Scope of Services: The medical services to be provided will be based on your individual health needs and may vary from general wellness care to specialized medical interventions. These services are intended to be conducted during in-home visits, where the affiliated healthcare provider will perform the agreed-upon medical care, tests, procedures, and supply the necessary medical equipment and supplies.
Informed Consent: Before receiving any treatment, you will be informed about the specific nature of the proposed medical services, the expected benefits, and the potential risks and side effects associated with them. I agree that Checkmate has communicated to me the risks and benefits associated with each treatment that I receive and have had an opportunity to ask the practitioner any questions I have on the risk associated with treatments/services that I receive. Knowing each of those risks, I am agreeing to proceed with services from Kings Medical PC. I understand that there is no implied or stated guarantee of success or effectiveness of any treatment. There has been no representation that any procedure is covered under my insurance plan or that I will receive reimbursement. I agree to pay the full cost of the service regardless if the treatment is stopped at any time prior to completion at the discretion of the medical provider or myself. Checkmate ensures that all patients are given enough information to make informed decisions about their healthcare, respecting patient autonomy and promoting informed choice.
Medical Services and Care
During an in-home visit, the attending provider may deliver and perform agreed-upon medical care, tests, procedures, and other necessary services.
You acknowledge having been informed of the risks and benefits associated with each treatment and have had the opportunity to ask questions regarding the risks associated with the services received.
INFORMED CONSENT FOR TREATMENT WITH PEPTIDES: I am executing this consent to confirm my discussion with Checkmate Health and my understanding of the risks, benefits, and alternatives to treatment with peptide therapy.The goals and possible benefits of this therapy are to try and prevent, reduce or control the dysfunction associated with the aging process, through hormonal balancing, control of oxidative stress, and stimulating the body's own innate repair systems. However, I understand that this treatment may be viewed by the mainstream medical community as new, controversial,and unnecessary by the Food and Drug Administration (FDA). The following are examples of some of the possible minor risks/adverse reactions reported for the peptide therapy that may be prescribed for me. At prescribed doses, there are not expected to be any significant risks/adverse reactions as long as full medical disclosure is achieved from the patient during the total time of therapy. For injectable CJC 1295/Ipamorelin adverse reactions include injection site redness, flushing, transient high blood sugar, development of antibodies to CJC 1295, and water retention. These side effects are dose related and usually eliminated by adjusting the dosage. This drug shouldnot be used in patients with known cancer. Oral or sublingual CJC/Ipamorelin doesn’t have any known side effects. For BPC 157 adverse reactions include injection site redness. Oral BPC-157 does not have anyknown side effects. By signing this form, I understand the possible risks associated with this treatment. I understand that Checkmate Health Strategies will monitor my treatment in an effort to manage any side effects, but cannot guarantee that I will not experience any side effects or adverse reactions. I understand that, as with any health treatment, there is no guarantee I will obtain satisfactory results through the use of this therapy. I certify that I have read the foregoing Informed Consent, discussed the issues noted above,had opportunities to ask questions, and agree and accept all of the terms above.
IV Therapy Consent
You consent to receive intravenous (IV) and mineral therapy as administered by Checkmate’ associated providers.
You have been informed of possible risks such as discomfort, thrombophlebitis, fatigue, allergic reactions, and others.
You agree to notify Checkmate of any pre-existing conditions like diabetes or heart disease that may affect the therapy.
Understanding and Agreement
By signing below, you acknowledge that you understand the terms of service and consent to the medical services provided by Checkmate Health. You affirm that all your questions have been answered satisfactorily and you agree to proceed with the treatments as discussed.