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  • VIGEO Health - CLIENT CONTACT FORM

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  • VIGEO Health Policies and Client Consent

    If you have any questions, please feel free to ask us. Please initial each point acknowledging you understand that:

  • I have read, understand, and agree to all of the above statements. (Sign and date below)

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  • VIGEO Health Informed Consent for Peptide Therapy

    Information and Consent for the Use of Peptides

    (Dawn Westrum and VIGEO Health) do not sell peptides, rather advice about use, dosage, and duration of peptide therapy and make recommendations on where to purchase them safely. Our recommendations are always 3rd party tested.

    Specific peptide recommendations made to you by (Dawn Westrum and VIGEO Health) are always optional.

    Peptides are amino acids that have biological activity which mimic certain hormones within the body. Certain peptides are FDA approved for the treatment of various diseases while other peptides are investigational new drugs that are not FDA approved to be marketed for consumption to humans even though clinical trials have shown them to have a favorable safety profile.

    Peptide therapy for the purpose of preventative care, weight loss, performance enhancement, anti-aging, and any additional condition discussed by (Dawn Westrum and VIGEO Health) is considered by the FDA to be “off-label use.”

    Peptides sold outside of compounding pharmacies are required to be labeled Not For Human Consumption and For Research Use Only. However, they are the exact same product as sold in compounding pharmacies, 3rd party tested for quality, purity, and content.

    Peptide therapy can be administered either orally, subcutaneously, intramuscularly, intravenously, or intranasally.

    I understand that peptide therapies are not necessarily approved for my medical conditions and they are not a medical necessity, rather, they are an adjunctive and complimentary therapy to my treatment plan. Therefore, I acknowledge that it is an elective treatment option.

    (WOMEN ONLY) There has been little research regarding the safety of peptide therapy in pregnant and breast-feeding women. I certify that I am not pregnant nor plan on becoming pregnant while on peptide therapy.

    I understand that with any drug, peptide therapies can carry potential side effects, including but not limited to: Rash, fever, nausea, vomiting, allergic reactions, decreased insulin sensitivity, flushing, headache, fatigue, lightheadedness, abdominal cramping, joint pain, fluid retention, and additional side effects not listed.

    I understand that alternatives to peptide therapy are: Doing nothing / FDA approved standard medication treatments / Referral to specialists / Surgery

    I acknowledge that there are no guarantees relating to the efficacy of peptide therapies and that (Dawn Westrum and VIGEO Health) are not responsible for my individual performance and ability to also exercise and diet.

    I will notify (Dawn Westrum and VIGEO Health) immediately if I have any concerns or side effects.

    I certify that I have had the risks and benefits discussed with me about peptide therapy and that I have had all my questions and concerns answered to my satisfaction by (Dawn Westrum and VIGEO Health).

    I hereby voluntarily consent to be evaluated by (Dawn Westrum and VIGEO Health) with the goal of improving my health, performance, and possibly delaying the effects of aging through peptide therapies.

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  • HIPPA Privacy Policy

    OUR LEGAL RESPONSIBILITIES

    We are required by law to give you this notice. It provides you on how we may use and disclose protected health information about you and describes your rights and our obligations regarding the use and disclosure of that information. We shall maintain the privacy of protected health information and provide you with notice of our legal duties and privacy practices with respect to your protected health information.

    We have the right to change these policies at any time. If we change our privacy policies, we will notify you of these changes immediately. This current policy is in effect unless stated otherwise. If the policy is changed, it will apply to all your current and past health information.

    You may request a copy of our notice any time. You may contact VIGEO Health at 801-834-1234 at any time to request a copy of this privacy policy.

    HOW WE MAY USE OR DISCLOSE YOUR PROTECTED HEALTH INFORMATION

    The following examples describe ways that we may use your protected health information for your treatment, payments, healthcare operations etc. but please be advised that not every use or disclosure in a particular category will be listed.

    Treatment: We may use and disclose your protected health information to provide you treatment. This includes disclosing your protected health information to other medical providers, trainees, therapists, medical staff, and office staff that are involved in your health care.

    For example, your medical provider might need to consult with another provider to coordinate your care. Also, the office staff may need to use and disclose your protected health information to other individuals outside of our office such as the pharmacy when a prescription is called in.

    Health Care Operations: We may use or disclose your protected health information in order to operate this medical practice. These activities include training students, reviewing cases with employees, utilizing your information to improve the quality of care,and contacting you be telephone, email, or text to remind you of your appointments.

    If we have to share your protected health information to third party "business associates" such as a billing service, if so, we will have a written contract that contains terms that will protect the privacy of your protected health information.

    We may also use and disclose your protected health information for marketing activities. For example, we might send you a thank you card in the mail with a coupon for specialized services or products. We may also send you information about products or services that might be of interest to you. You can contact us at any point to stop receiving this information.

    We will not use or disclose your protected health information for any purpose other than those identified in this policy without your specific, written Authorization. You may give us written authorization to use your protected health information or to disclose it to anyone for any purpose. You can revoke this authorization at any time but will not affect the protected health information that was shared while the authorization was in effect.

    Appointment reminders: We may contact you as a reminder that you have an appointment for your initial visit, follow up visit, or lab work via text, phone or email.

    Others Involved in Your Health Care: We may disclose protected health information about you to your family members or friends if we obtain your verbal agreement to do so, or if we give you an opportunity to object to such a disclosure and you do not raise an objection. For example, we may assume that if your spouse or friend is present during your evaluation, that we can disclose protected professional information to this person. If you are unable to agree or object to such a disclosure, we may disclose such information as necessary if we determine that it is in your best interest based on our professional judgment if there is an urgent or emergent need.

    Research: We will not use or disclose your health information for research purposes unless you give us authorization to do SO.

    Organ Donation: If you are an organ donor, we may release protected health information to organizations that handle organ procurement or organ, eye or tissue transplantation if it is necessary to facilitate this process.

    Public Health Risks: We may disclose your protected health information, if necessary, in order to prevent or control disease, report adverse events from medications or products, prevent injury, disability or death. This information may be disclosed to healthcare systems, government agencies, or public health authorities. We may have to disclose your protected health information to the Food and Drug Administration to report adverse events, defects, problems, enable recalls etc. if required by FDA regulation.

    Health Oversight Activities: We may disclose protected health information to health oversight agencies for audits, investigations, inspections or licensing purposes. These disclosures might be necessary for state and federal agencies to monitor healthcare systems and compliance with civil law.

    Required by Law: We will disclose protected health information about you when required to do SO by federal, state and/or local law.

    Workman's compensation: We may disclose your protected health information to workman's comp or similar programs.

    Lawsuits: We may disclose your protected health information in response to a court action, administrative action or a subpoena.

    Law Enforcement: We may release protected health information to a law enforcement official in response to a court order, subpoena, warrant, subject to all applicable legal requirements.

    YOUR RIGHTS REGARDING YOUR PROTECTED HEALTH INFORMATION

    Access to medical records: You have the right to access and receive copies of your protected health information that we use to make decisions about your care. You must submit a written request to obtain your protected health information to the individual listed at the end of this privacy policy. We reserve the right to charge you a fee for the time it takes to obtain and copy the protected health information and provide it to you.

    Amendment: If you believe the protected health information, we have about you is incorrect or incomplete, you may ask us to amend the information You will need to submit a written request on why you feel the health information should be amended. We may deny your request to amend if you did not send a written request or give a reason on why it should be amended. If we deny your request, we will provide you a written explanation. We may deny your request if we believe the protected health information is accurate and complete.

    Accounting of Disclosures: You have the right to receive a list of instances in which we disclosed your personal health information unless the disclosure was used for treatment, payment, healthcare operations, was pursuant to a valid authorization and as otherwise provided in applicable federal and state laws and regulations. You must submit a written request to obtain this "accounting of disclosures" to the individual listed at the bottom of this policy. After your request has been approved, we will provide you the dates of the disclosure, the name of the individual or entity we disclosed the information to, a description of the information that was disclosed, the reason why it was disclosed, and any additional pertinent information. This information may not be longer than (STATUTE OF LIMITATIONS) years ago prior to the date the accounting is requested. We reserve the right to charge a reasonable fee for this process.

    Restriction Requests: You have the right to request a restriction or limitation on the protected health information we use or disclose about you for treatment, payment, or healthcare operations. We shall accommodate your request except where the disclosure is required by law. We require this be a written request submitted to the individual at the end of this policy.

    Confidential Communication: You have the right to request that we communicate with you about healthcare matters in a certain way and at a certain location. We must accommodate your request if it is reasonable and allows us to continue to collect payments and bill you.

    Paper copy of this notice: You may request a hard copy of this practice policy if you reviewed and signed it via electronic means. To obtain this copy, contact the individual at the end of this privacy policy.

    Complaints: If you believe your privacy rights have been violated, you may file a complaint with our office. You also file a complaint with the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

  • Please sign below, indicating you have read and understand your Patient Rights.

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  • VIDEO CLIENT QUESTIONNAIRE

  • Recent Blood Test Information:

  • What is your typical diet? (Foods you generally eat in an average 48-hour period)

  • OLIGOSCAN QUESTIONNAIRE

  • Describe your daily Perspiration (Sweating) levels from the following activities:

  • HEALTH CONCERNS CHECKLIST

  • SUPPLEMENTS CHECKLIST

    Please check all boxes of supplements or prescriptions you have taken, both previously and currently. (Leave blank any that do not apply)

  • HORMONES/DOSAGES

  • List any medications you are taking and their dosages:
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