Clone of Concierge Wellness Intake Form

Corticosteroid Injection Intake and Consent Form

Secure and Confidential HIPAA Compliant Form. Fill this out before your 1st visit for Weight Loss, Vanquish ME Fat Reduction, Concierge Medical Care, Shockwave Treatment for Tendon or Joint Pain, Shockwave Treatment for ED, Wellness Programs, Lab Tests, Supplement Plans, Hormone Balance, Diabetes, Hypertension, High Cholesterol, Colds, and other Medical Care.
Please complete this form as accurately as possible. IT WILL TAKE YOU 10 MIN OR LESS BUT SAVE YOU TIME AT YOUR APPOINTMENT. This information will be needed for safe and proper care at VIP Health and Laser. Information will be sent by electronic encryption and will be placed into secure medical records. After you sign, you will be directed to the appointment page. Thank you!
Today's Date*

MonthDayYear
SECTION 1: PERSONAL INFORMATION
Full Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Email*
example@example.com
Phone Number*

Area CodePhone Number
Emergency Contact*

Area CodePhone Number
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
How did you hear about us?
SECTION 2: HIPAA FORM
HIPAA Notice of Privacy Practices

This is a notice required by HIPAA (Health Insurance Portability and Accountability Act of 1996) that explains how we at VIP Health and Laser keep your information private. It explains how we use, share, and protect your health information. This notice explains your privacy rights. After reviewing this form, sign below to acknowledge that you have received this form. You may contact us at any time if you have questions about this form or wish to have it in writing.

Protected Health Information (PHI) submitted to us via web forms is encrypted during storage and transmission on HIPAA compliant servers and held in strictest confidence. We do not give out, exchange, barter, rent, sell, lend, or disseminate any information about applicants or clients who apply for or actually receive our services. Any information you send or communicate to us is considered confidential and is specifically restricted by a patient/client-healthcare provider relationship. You may request that we communicate in an alternative confidential manor.

PHI may be used for treatment of health conditions. We perform care evaluations using history and physical exams to offer options for treatment. PHI may be used in a minimally necessary fashion for payments, billing, marketing, and for training of staff. PHI may be used to help you find health services and benefits to achieve your health goals.

We may receive requests from authorities or government agencies to disclose PHI if it necessary to convict a criminal. PHI may be used by government authorities to help avoid or resolve a threat to public health or safety. The Food and Drug Administration may request PHI regarding product recalls or to report adverse events. PHI may be used as required by law to report cases of abuse or neglect.

You have the right to receive a copy of your health records. You have the right to inspect, review, and receive a copy of your medical records and billing records. You may request to add a correction to your health information.

We may use before and after photos to show treatment benefits to other clients or potential clients. In these cases we cover eyes and identifying body features. We do not provide PHI with any photos. A separate consent form will need to be signed by you to allow this.

To file a complaint if you think your privacy rights have been violated, you can report it to U.S. Department of Health and Human Services Office for Civil Rights. You can request a copy or view a copy of this at any time in our “Terms” on our website, viphealthandlaser.com. If any of this is unclear you have the right to have us explain this to you at any time.
I ACKNOWLEDGE THAT I HAVE RECEIVED THIS HIPAA PRIVACY STATEMENT. THIS DOES NOT MEAN THAT YOU HAVE AGREED TO ANY SHARING OF YOUR PROTECTED HEALTH INFORMATION.I REFUSE TO ACKNOWLEDGE THAT I HAVE RECEIVED THIS HIPAA PRIVACY STATEMENT. REFUSING DOES NOT PREVENT US FROM USING OR DISCLOSING PHI AS HIPAA PERMITS. WE ARE ONLY REQUIRED TO DOCUMENT IT.
SECTION 3: HEALTH SCREENING
Chief Complaint: What brings you to VIP Health and Laser for this appointment? *
Do you have any concerning symptoms today or the past 2 weeks? If so, please note below:
Laser Spot TestLaser Hair RemovalLaser Toenail FungusLaser TendonitisLaser Muscle StrainFacial Skin TighteningLaser for OsteoarthritisLaser Varicose VeinsLaser Spider VeinsLaser for Muscle or Joint PainFacialsFacial Wrinkle InjectionsAcute Care Medical VisitChronic Care Medical VisitLab Testing & InterpretationNutraceuticals Vitamins or Supplement PlanHormonal BalanceWeight LossMedication ReductionLower CholesterolHypertensionDiabetesSports InjuryExercise PrescriptionAnti-agingMigraine ControlColds or FluMuscle BuildingAthletic PerformanceCancer PreventionHeart DiseaseOptimize General HealthNutrition for Health GoalsChronic FatigueOther Health GoalsMedical Care VisitVanquish ME Fat ReductionMicroneedlingPlatelet Rich Plasma (PRP)Erectile DysfunctionED Shockwave TreatmentShockwave Musculoskeletal PainDermal FillersHydrafacial or Hydradermal abrasionFemale Sexual DysfunctionPlasma Fibroblast PenDermaplaning facialO-shot or P-shot with PRPGaineswave ED TreatmentIV Vitamin InfusionsHair Restoration for Men or WomenOther
List other health goals if any:
What have you tried before to help the health conditions mentioned above?
abdominal painAccutane useacid peelacneactive suntan < 3 weeks agoallergic rhinitis (nasal allergy)anaphylaxis (severe allergy with throat swelling)anxietyasthmaataxia (unsteady walk)black tar-like stoolsbleedingbleeding disordersblisters around mouthbloody stoolsbloody urineblurred visionbony tendernessbright red blood per rectumbrown spotscancerchange in visionchest painchildbirthschillsclogged porescold intoleranceconfusioncosmetic surgerycoughcoughing up blooddark skin spotsdepressiondermatitisdiabetesdiarrheadifficulty hearingdiplopiadrinking fluids constantlydifficult to swallowdyspnea (difficulty breathing)painful urinationear paineasy bruisingeczemanose bleedsfatiguefertility problemsfeverfragile or very dry skinfrequent urinationfrequent coldsnevus (moles)hard bumps under skinheadacheshearing lossheart problemsblood in urinecoughing up bloodherpes simplexherpes simplex or blistershigh blood pressurehigh cholesterolHIVhormonal problemsdark spots on skinimmune deficiencybladder not emptyinginsomniaitchingjoint painjoint tendernessKeloid skin or scarringkeloids or scarslarge poreslaser hair removallightheadednessliver diseaseloss of visionlower extremity edemalupusswollen glandslarge amounts of urineblack stoolsmicrodermal abrasionmouth soresmuscle spasmnasal congestionnasal drainagenauseaneck lumpsneck painneck stiffnessneck swellingnose bleedspainful urinationpalpitationspetechiae (red dots over the skin)pneumococcal vaccinepolycystic ovary diseaseexcessive thirstexcessive urinationpoor bladder emptyingpainpregnantpsoriasisrashreceived flu vaccine this yearredness of skinringing of the earssarcoidosisscarssclerodermaseasonal allergiesseizuresShingles in past 3 monthsshortness of breathsinus painskin cancerskin rashskin sensitive to lightsore throatsun blisterssun damagesun spotssurgery with metal hardwaretemperature intolerancetendinitisthyroid diseasetoenail fungustrying to get pregnant nowunwanted hairupper lip linespassing outvertigovomitingweak urine streamwheezingwhite skin spotswrinkle fillerwrinklesnone of the above
List Past Medical History, Surgery, and Hospitalizations (Be Brief)
YesNo
If so, please list:
YesNo
If so, please list:
omega 3fish oilvitaminssupplementsantibioticsibuprofenAleveanticoagulants or blood thinnersphotosensitizing medicationoral contraceptiveshormone replacement therapynone of the above

Family History: Click below to report medical problems in the family.

Rows	No Medical Problems	Cancer	Heart Disease
Mom
Dad
Brothers
Sisters
Grandfathers
Grandmothers

Family History Continued.

Rows	High Blood Pressure	Diabetes	Stroke
Mom
Dad
Brothers
Sisters
Grandfathers
Grandmothers

ChildrenDaily Alcohol UseDenies illegal drugs or street drugsDivorcedI do not use any illegal drugs or street drugsI Never Drink AlcoholIllegal drug useMarijuana useMarriedMonthly Alcohol UseNever Drinks AlcoholNever SmokedNone of theseOccasionally Alcohol UsePermanent make upSingle (Not married)Spray tansStrokeSun tanningTanning bed useTattoosTobacco useToxic Chemical ExposureWeekly Alcohol UseOther
Number of Years Smoking and Average Number of Packs per Day
ALMOST DONE!

FINAL SECTION 4A: CONCIERGE WELLNESS CONSENT
OPTION 1) CONCIERGE WELLNESS ANNUAL RETAINER INCLUDING MEDICAL CARE AND WEIGHT LOSS SERVICES: Annual Retainer (12 month, 365 day period, maximum of 12, 60 minute visits per year. The 12, 1 hour visits can be used as often as once per week or as little as once every 6 months. Appointment frequency depends on what medical issues will need to be addressed and the time required to do so. Visits must be completed within ONE YEAR from contract signing or payments and visits will be forfeited.OPTION 2) CONCIERGE WELLNESS OR VIP WEIGHT LOSS PAY PER VISIT: Any desired health goals may be addressed during this one visit plus one follow up.OPTION 3) VANQUISH ME WITH VIP WEIGHT LOSS: Weekly treatments with the Vanquish ME. This program includes individualized medical weight loss services provided during Vanquish ME treatments only. A custom nutrition and exercise program will be personally designed to suit individual preferences. This VIP WEIGHT LOSS PROGRAM is advised to be done with Vanquish ME but is not required.OPTION 4) VANQUISH ME ONLY: Weekly treatments with the Vanquish ME only. Some basic nutrition and exercise program will be provided.
GENERAL MEDICAL CONSENT FOR TREATMENT. Acknowledge that you have read each section below by checking the box.
VIP Health and Laser, Gainesville, FL provides Concierge Medicine and wellness guidance for optimum health. All appointments are provided by a physician assistant supervised by a medical director. Programs are custom designed to achieve your personal health goals. We utilize patient care experience and the top research in medicine, nutrition, nutraceuticals, and exercise to form treatment plans. We take findings from history and physical exam, dietary habits, medications, laboratory testing, and lifestyle habits to provide you with the highest probability of success. This service is not covered by insurance.
Concierge Medicine and Wellness Services Overview: 1. Program introduction with practitioner. 2. Review of medical history and previously completed labs and tests. 3. Physical exams if required. 4. Basic lab testing included (blood count and complete metabolic panel) plus others available at wholesale rates 5. Research-evidence-based vitamin, herb, and food supplementation (supplements available at additional cost). 6. Intensive Wellness Medicine services and counseling far beyond what health insurance and Medicare covers. 7. Cell phone, email, and text provider access for non-urgent issues 9-5 regular business hours (please allow up to 6 hours for reply). 8. Urgent concerns for personal health. Call 24 hours, 7 days. 9. Detailed dietary modification with extensive nutritional interventions and incorporation of specific foods for desired health goals. 10. Research-evidence based vitamins, herbs, and supplements to reach specific health goals. 11. Exercise program design for optimizing desired health goals. 12. Prescription refills. 13. Same day or next day appointments if the health issue is not immediately addressed over the phone or by other means.
I or ("I" meaning the person receiving the services), the undersigned, hereby request and consent to the services provided within the scope of practice afforded by licensed healthcare professionals and clinical staff members of the Concierge Medicine Program at VIP Health and Laser, Gainesville, FL. I or my legal representative understand that any recommendations and care received at the Concierge Wellness Program or VIP Weight Loss at VIP Health and Laser, Gainesville, FL are supportive to your care needs, but do not in all cases substitute for regular medical care. I understand that I must continue to see my other previous treating healthcare providers as directed by them and take my regular medications as prescribed.
VIP Health and Laser, Gainesville, FL charges a fee for contract services and will not bill insurance even if services described here are billable with insurance. Signing this contract is for intensive supplemental healthcare in addition to your medical insurance policies. If you desire only standard services covered by health insurance, please do not sign this contract. I acknowledge that I am entering into an agreement for VIP Health and Laser Concierge Medicine and Wellness Programs in Gainesville, FL to provide the services specified herein to me within the desired contract period. I acknowledge and agree that this agreement has not been entered into at a time when I am facing an emergency or an urgent health care situation.
VIP Health and Laser may evaluate medical history, lifestyle, and previous laboratory and other previous test results; Physical examination as indicated to be necessary and lab diagnostic testing at wholesale rates for the contract period; Medical recommendations and management for disease prevention and healthy aging, which may include: nutrition, food medicine, nutritional supplementation, exercise, lifestyle behaviors, stress management, hormone replacement therapy, and other interventions as indicated by medical history, physical examination and laboratory parameters. I or my legal representative understand that I have the right to question any therapy proposed and/or provided by VIP Health and Laser, and that all of my questions will be answered prior to receiving such treatment.
I or my legal representative understand that I have not been and will not be given a guarantee of beneficial or specific results. I affirm that I have and will always, to the best of my ability, disclose my complete current and past medical history to VIP Health and Laser. I understand this history is essential for VIP Health and Laser to assess and provide competent care to me. I understand that the treatment I receive from VIP Health and Laser and its health care professionals is in large part based upon my disclosures to them. I have the right to revoke this Consent and contract after the specified contract service period. The service period can be extended annually with recurrent annual billing. There are no refunds for services provided.I understand that I am responsible for full payment of services when they are rendered. VIP Health and Laser will not bill my insurance company and I understand that my tax-deductible health plan will not reimburse me for services provided.
I or my legal representative understand that VIP Health and Laser and Matthew Obal, MS, PA-C are not excluded from any health insurance plans, but VIP Health and Laser services are not covered by insurance and I am financially responsible for all professional services, regardless of insurance coverage. I or my legal representative understand that if I have insurance or Medicare, these services will not be covered nor will they be billed for our services. I understand that third party insurance, commercial insurance or Medicare rates and coverage are much different than VIP Health and Laser services. I or my legal representative agree not to submit a claim to third party insurance, commercial insurance or Medicare for services offered as part of this contract or to ask VIP Health and Laser to submit a claim to third party insurance, commercial insurance or Medicare. I or my legal representative understand that third party insurance, commercial insurance or Medicare payment will not be made for any services offered as part of this contract.
I agree that I am entering into this contract with the knowledge that I have the right to obtain third party insurance, commercial insurance or Medicare covered items and services. I have not been compelled to enter into this private contract. I or my legal representative understands that third party insurance, commercial insurance or Medicare health plans do not, and that other supplemental plans may elect not to, make payments for services offered as part of this contract. The supplements included may not have been adequately evaluated for their effects on differing patient populations. Companies producing these supplements may contain extreme variability in the concentration of the desired ingredients within their products. Products should be purchased with standardization whenever possible. Most supplements have not been researched in patients with specific diagnoses, children, pregnant patients, and patients while breastfeeding. Therefore, unless the treatment has been researched in these patient populations, the treatment should never be used by them.
Medical care at VIP Health and Laser has not been designed to substitute all care of a primary care provider, but it is intended to assist and supplement this care. Medical care at VIP Health and Laser is provided as an intensive supplemental care plan to guide and enhance wellness with specific interventions in medicine, exercise, nutrition, and nutraceuticals.I affirm that I have read or have had read, and fully understand the information contained in this agreement. I have been advised of the risks and benefits of the services provided to me, and I have had the opportunity to ask questions regarding services. I understand this Consent covers the entire course of treatment provided by VIP Health and Laser. We take all or our clients seriously and make every effort to provide VIP service for everyone. We need to fit everyone in our schedule by fulfilling the demand. If appointments are cancelled in less than 24 hours in advance, or the client is a "no-show" we impose a $30 inconvenience fee.
I consent to a corticosteroid (steroid) injection into a joint or tendon sheath. This procedure involves cleaning the skin with an antiseptic and using a needle to deliver medication directly to the area of inflammation to reduce pain and improve function. Local anesthetic (numbing medicine) may be mixed with the steroid for immediate relief. Risks and Possible Complications: While generally safe, this procedure carries specific risks. By signing, the patient acknowledges the following potential complications: Infection: Though rare, any needle entry can introduce bacteria into the joint or sheath.Pain & "Steroid Flare": A temporary increase in pain and inflammation may occur for 24–48 hours after the injection.Bleeding: Bruising or localized bleeding at the injection site.Skin Dimpling & Color Changes: Thinning of the skin (fat atrophy) or lightening of skin pigment (depigmentation) near the site. Tendon Rupture: In rare cases, the tendon may weaken or tear following an injection. Nerve Injury: Temporary or permanent numbness, tingling, or weakness if the needle contacts a nerve. Elevated Blood Sugar: Corticosteroids can cause a temporary spike in blood glucose levels, which is particularly important for patients with diabetes to monitor.
Benefits, risks, and alternatives have been discussed with the healthcare provider for corticosteroid injection. There has been an opportunity to ask questions and I give consent for the procedure.I DO NOT CONSENT TO ANY MEDICAL TREATMENT.
I consent to Concierge Medicine Annual Retainer (12 month, 365 day period, maximum of 12, 60 minute visits per year. The 12, 1 hour visits can be used as often as once per week or as little as once every 6 months. Appointment frequency depends on what medical issues will need to be addressed and the time required to do so. Visits must be completed within ONE YEAR from contract signing or payments and visits will be forfeited
I consent for Vanquish ME, and understand that Vanquish ME body sculpting is used for eliminating pockets of fat. Body sculpting does not result in weight loss, but it can remove fat from areas where diet and exercise has been unsuccessful. It can also be used for either kick-starting or ending a weight loss program to drop several inches and pants sizes. I need to remain still for 45 minutes during the procedure. I can move a little up and down or side to side to adjust position and help the machine warm the body fat more evenly. Maintain communication with the technician so they can confirm you are in a good position for the treatment at all times. The area will become warm but not hot. If I feel a burning sensation or if it feels hot on the surface of the skin, I will let the technician know to adjust the machine.
I consent for vanquish ME and understand that redness over the skin of the abdomen is due to heat and resolves over minutes up to 2 days. Sweating during the procedure is common, so we use a fan to help cool you off. There is usually no pain or downtime and you may return to all of your previous activities. Some develop one or more tender lumps under the skin which forms from fat being surrounded by fibrous tissue. Over time, this will go away with gentle massage, ibuprofen, and moist compresses. Treatments will be placed on hold until the tenderness resolves. 5% of treatments can result in a small superficial blister on the surface of the skin. This can occur after the machine heats up sweat droplets on the skin surface. Your technician will need to be notified of any sweating under the machine applicator on the skin surface. A fan will be directed on the area to keep the skin dry.
I consent for Vanquish ME and understand that Vanquish ME produces electromagnetic energy which may cause heat to build up in jewelry or metal devices. All metal jewelry will need to be removed. Cellphones, Ipads, or electronic devices may not be used near the machine which causes interference in these devices. Any patients with metal implants are contraindicated and should not have Vanquish ME treatments. Dental implants are OK. Patients with internal plates, screws, pacemakers, and electronic implanted devices should never be treated with BTL Vanquish ME. Vanquish is not permitted for those who are pregnant or nursing. Those of childbearing age who are sexually active may need a pregnancy test before proceeding with Vanquish ME treatments. Women during menstruation should wait until the end of their cycle. Vanquish ME might heat up the area to cause vasodilation. As a result, the uterine lining might shed more quickly and vaginal bleeding may become heavier than normal.
Vanquish ME Consent: I consent to vanquish ME and will drink 3 quarts to 1 gallon of water daily including before, during, and after your session, as if working out. Let your provider know if your medical history limits fluid intake. The body needs water to help eliminate the broken down fat cells. Stay well hydrated daily during the course of your treatments to facilitate this process. I will wear comfortable loose fitting clothing for treatment. Workout clothes, spandex, t-shirts, gym pants or shorts would work well. I will not get up during the middle of the treatment. The machine will pause every 15 minutes in case bathroom break needed or if I need to do something important. My measurements, body part photos, bodyfat percentage and weight will be taken before the 1st session and after the treatments.
Vanquish ME Consent: I consent to Vanquish ME and I understand that the loss of the fat is permanent but I may enhance the results by adhering to an effective diet and exercise regimen. I can continue my previous exercise program after Vanquish ME. It is important to maintain results by not gaining weight. Exercise helps maintain lean body mass (muscle tissue) and promotes the loss of fat. Exercise can prevent the remaining fat cells from enlarging. If you lower your caloric intake to lose weight, your metabolic rate slows down. Use exercise to keep your metabolism higher as you cut calories. I understand that I will start seeing some results within 2 weeks. The body takes time to excrete the dead fat cells once they are damaged by radiofrequency. Over the course of 6-8 weeks after the sessions, many fat cells will dissipate, and the results will be fully noticeable.
I authorize a trained ESWT technician to performed ESWT on the affected areas. I understand that this therapy is non-invasive and uses high energy sound waves to treat painful spots in the joints, ligaments and tendons. The therapy is used for a variety of acute or chronic musculoskeletal conditions. The treatment will be provided by a trained ESWT specialist trained to do these type of treatment. The treatment will be performed with an Extracorporeal Shock Wave Therapy (ESWT) device which produces energy that promotes regeneration and repair processes of the bones , tendons and other soft tissues. ESWT is able to break up scar tissue, remove calcifications, and improve blood flow vital for the healing process.If I opt for this procedure, I understand it is usually temporary, but there can be an increase in pain during and after the procedure. I understand that there is a possibility that a pre-existing injury, a previous ligament or tendon tear or scarring or history of previous surgical repair may result in partial or complete tendon or ligament tear or rupture.I confirm that I do not have any of these contraindications for the procedure: 1) Pregnancy, 2) Bleeding disorders (use of blood thinners or hemophilia), 3) Blood clotting disorders (deep venous thrombosis or pulmonary embolism), 4) Steroid injection within the last 6 weeks, 6) Tumors or cancer at the treatment site, 7) Pacemaker placement, 8) Infection or open wound, 9) Under 18 years of age, 10) Treatment over an air filled area such as lungs or abdomen.I authorize the administration of topical and/or local anesthetic advisable for comfort, well-being or safety.I PROVIDE CONSENT FOR A TREATMENT COURSE FOR MUSCULOSKELETAL CONDITIONS WITH ESWT (EXTRACORPOREAL SHOCKWAVE TREATMENT)
I authorize a trained ESWT technician to performed ESWT on the affected areas. I understand that this therapy is non-invasive and uses low energy pressure waves to treat erectile dysfunction. The treatment will be provided by a trained ESWT therapist. These sound waves pass through erectile tissue. They have the ability to restore natural erectile function by clearing plaque out of blood vessels and encouraging the growth of new blood vessels.I understand that there can be an increase in pain, bruising, loss of sensation, or swelling during and after the procedure.I confirm that I do not have any of these contraindications for the procedure: 1) Bleeding disorders (use of blood thinners or hemophilia), 2) Steroid injection within the last 6 weeks, 3) Tumors or cancer at the treatment site, 4) Sexually transmitted disease, skin lesions, infection or open wound, 5) Under 18 years of age, 6) Sickle cell disease or priapism. 7) Neuropathy associated with diabetes, 8) Cortisone therapy within the previous 6 weeks.I have disclosed a history of any penile disorders or past treatments to the medical staff.I authorize the administration of topical and/or local anesthetic advisable for comfort, well-being or safety.I understand that the FDA has not approved ESWT for use on the penis in the United States.I PROVIDE CONSENT FOR A TREATMENT COURSE FOR ERECTILE DYSFUNCTION WITH ESWT (EXTRACORPOREAL SHOCKWAVE TREATMENT)
I consent to Vanquish ME Fat Reduction.I consent to Shock Wave Therapy for musculoskeletal conditions including joint, tendon, or back or ligament pain.I do not consent to any of the treatment options above.
FINAL SECTION 4B: PHOTO CONSENT
Consent for Photographs and Videos

I consent to allow personnel of VIP Health and Laser to take photographs and videos during the course of my therapy. Photos and videos may be used for showing the benefit of the procedures done at VIP Health and Laser to other clients or potential clients. The photos and videos may be used for social media channels, for documenting before and after results, for medical education, to offer other clients options and/or for the professional evaluation of treatment progress. You may request that the photos and videos not show your identity (cover eyes and/or face) by selecting below. Names are never provided with photos and videos but comments on the photos and videos are possible by viewers or outside parties.
I CONSENT TO ALLOW PHOTOGRAPHS AND VIDEOS AS DESCRIBED ABOVEI CONSENT TO ALLOW PHOTOS AND VIDEOS WITHOUT SHOWING MY IDENTIFYING FEATURES (EYES AND FACE)I DO NOT CONSENT TO ALLOW PHOTOGRAPHS OR VIDEOS.
FINAL SECTION 4C: EMAIL CONSENT
Consent for Email Communication

I consent to allow personnel of VIP Health and Laser to communicate information with encrypted email including but not limited to appointment reminders and laser therapy instructions. I consent to receive email at any email address that I provide to VIP Health and Laser. We may send you email up to 3 times weekly to provide notification about VIP Health and Laser services. Please note that we only send email by TLS encryption security protocol. If you opt out of email, it may be more inconvenient to receive services from us. There are risks with using email communication such as wrong address, forgery, phishing or use without authorization.
I CONSENT TO ALLOW EMAIL COMMUNICATION.I DO NOT CONSENT TO ALLOW EMAIL COMMUNICATION.
Message / Comments - Add other important information here as desired (Optional).
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PLEASE MAKE SURE TO REVIEW THE ABOVE FOR COMPLETENESS AND ACCURACY BEFORE SUBMITTING. BY SIGNING BELOW, I ATTEST THAT THE RISKS, COMPLICATIONS, BENEFITS, AND ALTERNATIVES HAVE BEEN EXPLAINED TO ME FOR ALL PROCEDURES AND MEDICAL CARE I CONSENTED TO ABOVE. I UNDERSTAND THAT THERE IS NO CERTAINTY THAT I WILL ACHIEVE THESE BENEFITS AND NO GUARANTEE HAS BEEN MADE TO ME REGARDING THE OUTCOME OF THE PROCEDURES PERFORMED. YOUR INFORMATION WILL BE ENTERED INTO SECURE MEDICAL RECORDS. YOU MAY REVIEW THE CONSENTS YOU SIGNED IN A SECURE EMAIL SENT TO YOU AT THE EMAIL ADDRESS YOU SPECIFIED. YOU MAY REQUEST A PRINTED COPY AT ANY TIME.
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Corticosteroid Injection Intake and Consent Form