Client General Consent The Good Life September 27, 2024

Client General Consent

Welcome to The Good Life and IV Therapy LLC. We are here to serve you and look forward to meeting your health care needs. This form sets out our standard terms and conditions relating to your treatment and certain policies and procedures. If you have any questions regarding this form, please call (480) 674-8268.

By signing this form, you as the client or the client’s legally authorized representative (“I” or the “Client”) agree that you are over 18 years of age and further agree to all the following:

  1. CONSENT TO TREATMENT: I am authorizing and consenting to all care and treatment provided by The Good Life and IV Therapy LLC and its affiliated health care providers, including physicians, physician assistants, nurse practitioners, nurses, medical assistants, and others. Through this consent, I am authorizing all examinations and care, including medical care, diagnostic examinations, and general medical health care services requested or ordered by my health care provider.
  2. CLIENT RIGHTS AND RESPONSIBILITIES: I acknowledge receipt of The Good Life and IV Therapy LLC’s “Client Rights and Responsibilities” and acknowledge that I have the responsibility to be involved in my care.
  3. CONSENT TO PHOTOGRAPH AND/OR VIDEO OR DIGITAL RECORDING: I consent to the recording, filming, and photographing of the me, including pictures and/or video or digital recordings of medical treatment, procedures, and progress for purposes of identification, treatment, and internal operations, such as, but not limited to, improvement of quality of care and educating students and professionals. I will not receive compensation for any such films, recordings, or photographs.
  4. COMMUNICATIONS: I authorize The Good Life and IV Therapy LLC to communicate with me by phone, text message or email at the telephone number(s) and/or email address(es) I provide. Such communications may be for, but are not limited to, appointment reminders, providing test results, information about available services, customer survey requests, marketing of goods and services, and other important notices related to my health care. I understand that email and text messaging are not secure methods of communication and there is some level of risk that the email or text message could be read by a third party. I understand and agree that such calls or messages may be sent using an automatic telephone dialing system or prerecorded or artificial voice. If I wish to have The Good Life and IV Therapy LLC communicate with me by alternative means or at alternative locations, I may request an accommodation by discussing my wishes with a staff member.
  5. TELEMEDICINE: I understand The Good Life and IV Therapy LLC may conduct a client visit with me by telemedicine, including by video or telephone, and that this will involve the electronic transmission of my medical information. I understand that with any internet or phone-based communication, there is a risk of security breach, even if The Good Life and IV Therapy LLC has implemented safeguards to prevent unauthorized access. I further understand that sometimes disruptions of signals or problems with internet or phone infrastructure may cause broadcast and reception problems (e.g., poor picture or sound quality, dropped connections, audio interference, etc.) that prevent effective interaction, in which case my provider may decide to reschedule my appointment. Last, I understand and agree that I have or will provide you with an accurate and complete medical history, understanding that you will not have access to additional medical records or information.
  6. NO INSURANCE COVERAGE: I understand this procedure is not covered by insurance, including Medicaid, and I am responsible for total payment to The Good Life and IV Therapy LLC for all such treatments.
  7. NO REFUNDS: All services must be paid for in advance. No refunds are available after a fee for a procedure has been paid and services rendered.
  8. CANCELATION POLICY: The Good Life and IV Therapy LLC has a cancelation policy of $50.00 if appointments are canceled within 1 day of the appointment time.