Acknowledgement & Consent Form
Please complete in addition to your Contact & Health History Form
Name
First Name
Last Name
I acknowledge I have received and may request a copy of Red Zone Health & Wellness, LLC Notice of Privacy Practices.
yes
I authorize and consent to the release of my personal health history and contact information for use in my personal care, payment, and business operations ONLY.
yes
I acknowledge that Red Zone Health & Wellness, LLC DOES NOT PROVIDE Primary Care Medical Services and provide my authorization and consent to coordinate exchange of information and recommendations regarding my care to achieve my Health & Wellness Goals with my established Primary Care Provider.
yes
I acknowledge and consent to the use of GLP-1 medications from a FDA approved and accreditated compounding pharmacy.
yes
I acknowledge that I have been informed of possible side effects and recommended precautions regarding the use of medications, supplements, and cosmedic products I have requested and purchased from Red Zone Health & Wellness, LLC. I acknowledge that I may request information regarding side effects of any product at any time. I acknowledge that I may discontinue use of products and services provided by Red Zone Health & Wellness, LLC at anytime without any fault or penalty.
yes
Signature
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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