Intake and Consent Forms

I attest that the information I have provided is true and accurate to the best of my knowledge:

MCS Restore Clinical Policies

PATIENT CONSENT FOR THERAPIES WITH MCS RESTORE.

If you have any questions, please feel free to ask us. Please review each point carefully and sign below acknowledging you understand that:

• Services must be paid for at the time of service. 

• Health insurance typically does not cover services provided at MCS RESTORE. If you want to seek insurance reimbursement, we would be happy to provide you with itemized invoices that you can submit to your insurance company. 

• I understand that treatments used at MCS RESTORE might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life. 

• I agree that if I am having any side effects or become sick, I will follow up with my primary care provider or go to an urgent care or emergency department. 

• I acknowledge that MCS RESTORE is 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 MCS RESTORE. 

• I understand that there are no refunds for services or products rendered.

• I understand that having an appointment with MCS RESTORE does not necessarily entitle me to have a treatment 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 MCS RESTORE in regard to therapies as determined by a mutual decision between myself and the medical provider even if it is not considered a medical necessity.

I have read, understand, and agree to all of the above statements.

This form outlines that you understand that a peripheral intravenous catheter will be inserted into a vein in your body, and you will have fluids, vitamins, minerals, nutrient, and/or medications infused directly into your body. This is considered “IV Infusion Therapy.” If you are having injection therapy, then you understand that a vitamin, mineral, nutritional compound, and/or medication will be injected directly into the subcutaneous fat or muscle of your body. This is considered “Injection Therapy.”

Please review each point below carefully and sign below acknowledging that:

• I understand that IV infusion and injection therapy at MCS RESTORE is not intended to diagnose or treat a specific medical condition.

• I understand that therapies offered will not prevent, treat, or cure any medical condition or disease. Furthermore, I understand that I am here seeking IV infusion and/or injection therapy voluntarily to assist with certain symptoms or ailments I may be experiencing.

• I have informed MCS RESTORE of all the medications, supplements, and allergies that I have. I understand that serious adverse events could happen if I do not disclose all of my drug/food/vitamin/and additional allergies and medications/supplements that I am currently taking.

   

• I understand that I have been informed of the procedure, the alternative treatment options, and the risks and benefits of the mutually agreed-upon treatment.

   

• I affirm that I am voluntarily seeking therapies at MCS RESTORE and have not been coerced into doing so.

• I understand the risks and benefits of the procedure and have had all my questions answered to my full satisfaction.

   

• I understand that I have the right to refuse any treatments or treatment recommendations at any time.

Pre and Post Visit Instructions

To have a safe and effective therapy session, it is important that you adhere to the following pre- and post-visit instructions.

Before your appointment:

• Plan to be at the clinic at least 15 minutes before your infusion to fill out necessary paperwork if you are a first- time patient.
• If you are a repeat patient, then arrive 5 minutes before treatment
• You can take your regular medications as normal on the day of treatment.
• We recommend a light snack and a bottle of water before treatment.

After your IV infusion:

• If any mild side effects occur such as hives, nausea, fever, cramping, headaches, or any additional non-life- threatening symptoms, please call MCS RESTORE at 618-797-0618 immediately. If it is after hours, then please report to your closest urgent care or emergency department.
• If any type of serious adverse events occurs such as diffuse hives, shortness of breath, trouble swallowing, chest pain, severe headache, changes in consciousness, increase pain/swelling in the arm that the infusion was given in, or anything else that is concerning, call 911 or report to the emergency department immediately.
• Hydrate!

If you have any additional questions or concerns, please feel free to reach out to MCS RESTORE at 618-797-0618.

I acknowledge that I understand the instructions that need to be followed prior to and after my treatment. I certify that I will follow these instructions and notify MCS RESTORE of any changes in my condition or drug/supplement use.

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 at any time. You may contact MCS RESTORE 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 with 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.

Payment: Your protected health information may also be used to obtain payment from an insurance company or another third party. This may include providing an insurance company with your protected health information for a pre-authorization for a medication we prescribed.

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 by telephone, email, or text to remind you of your appointments.

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, 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 the 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

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 why it should be amended. If we deny your request, we will provide you with 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 six 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.

Dr. Jonathon Brooks drjbrooks@multigc.com

Please sign and date indicating you have read and understand your Patient Rights.