This agreement between________________ (“Patient”) and PriorityYou Health Center, LLC establishes guidelines and conditions for the use of IV Vitamin and Hydration Therapy. PriorityYou Health Center, LLC and patient agree that these guidelines and conditions are an essential factor in maintaining a successful patient/practitioner relationship. Adverse side effects and/or physical/psychological dependence may develop after repeated use of these medications and therefore, these agents are prescribed with caution. The patient agrees and accepts the following conditions:

1. I understand that the Vitamins I am receiving for me based on diagnoses derived from my submitted medical history, and the results of lab work (if needed) and a physical examination. The medications are to be used exclusively for treatment of medical conditions in accordance with applicable state and federal law. 
2. I certify that the answers I provided to the health questions on the Health History laboratories are accurate and correct to the best of my knowledge and that I have not been coached by any third party nor have I knowingly been deceptive for secondary gain, for medical treatment or prescription of a medication.
3. I do not have any history of Diabetes, Congestive heart failure or any other type of heart disease.
4. I have discussed and understand the risks and benefits associated with IV hydration therapy. I will immediately report any adverse side effects related to my treatment to PriorityYou Health Center, LLC and discontinue use until advised to resume usage by my health care provider. I voluntarily assume any and all possible risks which may be associated with IV Hydration Therapy.
5. I understand that representatives of PriorityYou Health Center, LLC and/or licensed nurse practitioners and Anthony Kane M.D. are available for questions and/or concerns during normal business hours throughout the course of my treatment.
6. I understand that IV Hydration Therapy is not covered by health insurance. I agree that all services and medications provided by PriorityYou Health Center, LLC or its associated providers are to be paid in advance. I will not seek reimbursement through my health insurance company, Medicare, Medicaid, or other third-party payer.
7. I agree that the provider relationship is not intended to replace the existing patient/physician relationship with my current primary care provider (PCP) and the treatment provided by PriorityYou Health Center, LLC will be in conjunction with the care provided by my current PCP.
8. I agree that I will use my medication at the prescribed rate and dosage and will keep the medication in its respective labeled container. 

 

I have read and agree to the terms of this Therapy Management Agreement.