New Patient Registration

 

Direct Primary Care:

I voluntarily consent to receive medical care and treatment from Innovation Health. This includes, but is not limited to, medical evaluations, physical examinations, diagnostic testing, laboratory work, imaging, minor procedures, preventive care, and treatments deemed necessary by my healthcare provider. I understand that my treatment may involve physicians, nurse practitioners, physician assistants, nurses, and other healthcare professionals.

I understand that:

My provider will explain my diagnosis, treatment options, potential risks, and alternatives before proceeding with care.

I have the right to ask questions and receive clear answers regarding my condition and proposed treatments.

I may refuse any treatment or procedure at any time and understand that my provider will inform me of the potential consequences of refusal.

My healthcare provider may recommend referrals to specialists or additional diagnostic tests as part of my treatment plan.

TELEMEDICINE CONSENT (IF APPLICABLE)
I understand that if I receive telemedicine services, my provider will conduct remote evaluations using video, phone, or other electronic means. I acknowledge that telemedicine may have limitations, and I may be required to schedule an in-person visit if needed for further evaluation.

PRIVACY AND CONFIDENTIALITY
I acknowledge that my medical records will be kept confidential and used only for purposes related to my treatment, payment, and healthcare operations. I understand that my information may be shared with other healthcare providers involved in my care and as required by law. I have been informed of my rights under the Health Insurance Portability and Accountability Act (HIPAA) and understand that I may request a copy of the clinic’s privacy policy.

INSURANCE AND FINANCIAL RESPONSIBILITY
I understand that I am responsible for all charges incurred for my medical care. .

CONSENT DURATION AND REVOCATION
This consent remains in effect unless revoked in writing. I understand that I may withdraw my consent at any time, but this will not affect any treatment provided before the revocation date.

By signing below, I acknowledge that I have read, understood, and agreed to the terms of this consent form.

INDEMNIFICATION CLAUSE: I agree to indemnify, defend, protect, and hold harmless Innovation Health, its partners, employees and those affiliated from, against and in respect of all liabilities, losses, claims, damages, punitive damages, causes of action, lawsuits, administrative proceeding, investigations, demands, judgements, settlement payments, deficiencies, penalties, fines, interest, cost and expenses suffered, sustained, incurred, or paid by the indemnified parties in connection with, resulting from or arising out of, directly or indirectly Innovation Health practitioner rendering medical care, services, advice, and/or treatment. My failure to disclose all relevant medical information regarding my medical and physical condition, acts or omissions could cause harm or injury resulting from medical care or pharmaceuticals directly or indirectly provided by Innovation Health. I am aware of the risk and potential side effects with the above-described treatment, accept all risk involved in taking medications, and will not seek indemnification or damages from the indemnified parties. 

Here’s How Your DPC Membership Works: Congrats!! You are a part of our Direct Primary Care program. With your enrollment you can take advantage of a variety of benefits. You are now eligible for same day appointments, zero to minimal wait time in office, no copays, transparent pricing and discounted rates on labs and medications. You are also eligible for 10% off our other services such as medical weight loss, hormone replacement therapy, peptides, supplements, and IV Therapy. 

Recurring Payments: You authorize regularly scheduled charges to your debit/credit card. You will be charged each billing period for the total amount due for that period. A receipt will be emailed to you and the charge will appear on your bank or credit card statement. You agree that no prior notification will be provided to you for each scheduled payment.

*Please note that during your first visit, we will need to scan a form of ID to complete your registration as a patient. 

*If you would like to schedule your first appointment, you can do so below. Please note that with your subscriptions appointments are NOT neccessary. You can walk in any time during normal buissness hours.