To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform Custom Health Centers of any changes in medical status.

Agreement to Use Electronic Signatures and Electronic Documents

I agree that the electronic signatures included in this notice are intended to authenticate this writing and to have the same force and effect as manual signatures.

Electronic signature means any electronic sound, symbol or process attached to or logically associated with a record and executed and adopted by a party with the intent to sign such record, including (without limitation) typing a name or clicking a checkbox.

I agree to use electronic documents, notices and contacts "electronic documents", for all future transactions and communications. Electronic documents contain the same information as paper documents, notices and contracts. Paper documents, notices and contracts are available at my request. If I give my consent to use electronic documents, I can later change your mind and request a paper agreement instead.

Cancellation Policy

I agree to keep all scheduled appointments and be on time. If I cannot attend a scheduled session, I will contact Custom Health Centers to cancel and/or reschedule. There will be no fee if the appointment is canceled before 24 hours of the scheduled appointment time. I understand if I miss or cancel with less than 24 hours of notice, then I will be charged for the full price of the appointment.

Informed Consent for Telehealth Consultations

I understand that telehealth is the use of electronic information and communication technologies by a healthcare provider for the delivery of services to an individual when he/she is located at a different site than the provider. I hereby consent to Custom Health Centers providing healthcare services to me via telehealth.

I understand that the laws that protect the privacy and the confidentiality of health information also apply to telehealth. Custom Health Centers's telehealth services are provided by Kalix, Inc., GoHighLevel, Zoom, and Jotform, all HIPAA compliant platforms.

These platforms uses a secure browser-to-browser technology without the need to download or install any software. All data, video, audio, and files are encrypted in both transit and rest. Telehealth appointments are not recorded in any way, but I understand that I have the right to access any information resulting from the service, as required by law.

To join a telehealth appointment, Custom Health Centers will send me a secure link and code as part of my appointment confirmation and appointment reminder messages, which are sent through email or text message.

I understand that telehealth services are not the same as direct in-person appointment delivery because I will not be in the same room as the healthcare provider. The inability to have direct, physical contact with my healthcare provider is a primary difference between telehealth and direct in-person service delivery.

I understand there are potential risks to this technology, including interruptions and technical difficulties. I understand that Custom Health Centers or I can discontinue the telehealth appointment if it is felt that the telehealth connections are not adequate for the situation. Good internet download and upload speed is required for quality telehealth services. The recommended minimum upload and download speeds required is 2Mbps. I can conduct an internet speed test by clicking here. I understand that the quality of my video connection may affect the quality of services provided by Custom Health Centers.

I have had the alternatives to telehealth services explained to me, and I understand that my use of this technology is voluntary. I have the right to withhold or withdraw my consent to use telehealth in the course of my care at any time, without affecting my right to future care or treatment. I may revoke my consent orally or in writing at any time by contacting Custom Health Centers. As long as this consent is in force (has not been revoked), Custom Health Centers may provide healthcare services to me via telehealth without the need for me to sign another consent form.

Financial Policy

Custom Health Centers financial policy requires our company to collect payment for your care at the time services are rendered. We accept debit card, Mastercard, Visa, American Express, and Discover. We ask you to remember that the ultimate responsibility for full payment for our services rests with the adult patient or guarantor. If your account becomes delinquent and it becomes necessary for the account to be referred to an attorney or collection agency or suit, the patient or guarantor will be responsible for paying all patient charges, reasonable attorney fees, collection expenses, and court costs. Custom Health Centers, Inc is affiliated with multiple insurance companies and will attempt to bill out for services. In the case that your insurance provider covers the services you will only be responsible for the remaining balance.

It may become necessary to release your protected health information to financial parties, credit card entities, banks, and financing companies, when requested, to facilitate your payment. Services that are performed that are paid with a credit card, debit card, or financing third party are not eligible for payment challenges after services are provided. By signing this form, I am irrevocably consenting to allow Custom Health Centers, INC. to use and disclose my protected health information to any Credit Card Entity, Bank, or Financing company when they request such information to process an account and assist with payment.

I will not challenge such credit, debit, or financing card payments once the services are provided. The practice encourages complete post-op care and follow-up interaction to address any issues that might arise. I agree that this noncredit card challenge agreement is irrevocable.

Consent to Treatment

I have read through all the above information and have been clearly advised of my rights and responsibilities as a client of Custom Health Centers, including the HIPAA Notice of Privacy Practices.

Lab Draw Consent

My signature below acknowledges that:

1. This procedure involves inserting a needle into the vein and drawing a vial of blood.

2. Alternatives to blood draw, but are not limited to, testing available with your primary care or specialty physician outside of Custom Health Centers Inc.

3. The potential risks of blood draw include, but are not limited to:
I. Occasionally: Discomfort, bruising and pain at the draw site.
II. Rarely: Inflammation of the vein used for draw, phlebitis, metabolic
disturbances, and injury.
III. Extremely rarely: Severe allergic reaction, anaphylaxis, infection, cardiac
arrest, and death.

4. Benefits of Blood Draw and Full Panel Testing include:
I. Knowledge of baseline levels of the items listed on the order form reviewed with me by the Custom Health Centers, Inc provider.

I am aware that unforeseeable complications could occur, and I do not expect Custom Health Centers, Inc provider to anticipate or explain all possible complications.
I rely on the Custom Health Centers, Inc provider to exercise judgement during the course of my treatment.
I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.

I understand that I have the right to consent or refuse any proposed treatment at any time.
My signature affirms that I have given consent to draw blood with Custom Health Centers, Inc.

My signature below confirms that:
1. I understand the information provided on this form and consent to treatment.

2. The procedure(s) set forth above has been adequately explained.

3. I have received all the information and explanation I desire pertaining to the
procedure.

4. I authorize and consent to the procedure(s).

Consent for Off-label and No-label use

I understand that the prescribing of this medication and my use of it is either an off-label (non-FDA approved) use of this medication or that the medication does not have an approved use by the FDA. Off-label use of this medication means that the FDA has not approved the use of this medication for the purposes for which the doctor has prescribed it to me.

General Provisions

I acknowledge that the prescribing physician may use and disclose my information as necessary for the purposes of treatment, payment, and healthcare operations. This shall be done in a manner consistent with HIPAA regulations and applicable requirements. I intend this consent to be continuing in nature and that it will remain in full force until revoked in writing. A photocopy of this consent shall be considered as valid as the original. I have read or have had read to me all the above statements and understand them. I have had the opportunity to ask any questions I might have about the medication and the treatment being prescribed, any potential risks, and the alternatives prior to my informed consent. I give consent for this medication/treatment to be prescribed to me and for my use of it as directed by my physician.