General Medical Intake & Patient Consent
Version 7 | Please read carefully before signing.
? Before You Sign
- You must be 18 or older to receive technology, testing, medical services, or procedures.
- If you are 70 or older, a provider Good Faith Exam (GFE) is required before any wellness services.
- Signing as a Legally Authorized Representative? You must also complete the Next Health LAR Consent & Attestation form - request it from our clinical team.
General Consent, Waiver, Authorization & Privacy Acknowledgment
Version 7.0 | Please read carefully before signing.
PLAIN-LANGUAGE SUMMARY
This document explains your rights and responsibilities as a Next Health patient. By signing, you confirm that you:
- Consent to evaluation and treatment by Next Health clinical staff.
- Understand the nature, risks, and limitations of the services you are receiving.
- Agree that Next Health is not your primary care provider.
- Consent to the collection and lawful use of your health information.
- Acknowledge that certain services require medical clearance before participation.
- Agree to resolve disputes through binding arbitration (Section 43).
- Have had the opportunity to ask questions and received satisfactory answers.
Please read every section. If anything is unclear, ask a staff member before signing.
By presenting for services, you confirm all of the following:
- You are at least eighteen (18) years of age. Next Health does not provide services to patients under the age of 18.
- You have disclosed all relevant medical history, diagnoses, allergies, medications, supplements, and prior adverse reactions.
- You are not currently pregnant or breastfeeding.
- You are not under the influence of alcohol, recreational substances, or non-prescribed medications at the time of treatment.
Next Health provides wellness, preventative health, longevity, recovery, diagnostic, and technology-enabled services that may differ from conventional medical treatment. You understand that certain services, therapies, technologies, and protocols offered by Next Health may:
- Be supported by emerging scientific evidence that is not yet conclusive.
- Be considered investigational or experimental by some medical professionals or regulatory bodies.
- Involve off-label use of FDA-approved medications.
- Not be considered medically necessary by insurance carriers.
- Be elective in nature; your participation is always voluntary.
Next Health locations may be operated by independently owned and operated franchisees. Services at franchise locations are provided under the Next Health brand and standards, but the franchisee entity - not Next Health corporate - is the direct service provider at that location. References to "Next Health" in this document include both corporate-operated and franchisee-operated locations as applicable.
Certain services offered by Next Health require a prior Good Faith Examination ("GFE"), medical clearance, laboratory testing, imaging, specialist consultation, or written approval from a treating physician before participation is permitted. This requirement applies to, but is not limited to, the following service categories:
- Hyperbaric Oxygen Therapy (HBOT)
- Cryotherapy and whole-body cold exposure therapies
- Testosterone Replacement Therapy (TRT) and hormone protocols
- Peptide therapy and compounded medication programs
- IV and injectable therapies in patients with significant cardiac, renal, or hepatic history
- Any service where a provider determines that a clinical evaluation is necessary to confirm safe participation
Next Health reserves the right to deny, postpone, or discontinue any service if a licensed provider determines that participation may not be medically appropriate for you at that time. Such decisions are made in your best interest and do not constitute a breach of any service agreement or membership obligation.
Patients over age 70 or with significant cardiovascular, renal, pulmonary, or hepatic history may be required to provide written medical clearance from their primary care provider or specialist before participating in high-intensity services.
Next Health providers - including physicians, nurse practitioners, physician assistants, nurses, and other authorized clinical staff - reserve the right to decline, discontinue, postpone, or modify any treatment, prescription, protocol, procedure, membership benefit, or service if, in their professional judgment, the service is:
- Medically inappropriate or potentially unsafe for the patient
- Outside the provider's scope of practice or clinical expertise
- Inconsistent with applicable laws, regulations, professional standards, or licensing requirements
- Contraindicated based on the patient's current health status, medications, or recent lab results
- Not supportable by available clinical evidence for the patient's specific situation
This right is exercised in the interest of patient safety and professional integrity. Refusal or modification of a service does not entitle a patient to a refund of membership fees already paid, except as provided in the applicable Membership Agreement or as required by state law.
You expressly authorize Next Health physicians, nurse practitioners, physician assistants, nurses, and other authorized clinical staff to perform the following services as clinically appropriate during your care at Next Health:
- Health evaluations, wellness assessments, and functional medicine consultations
- Diagnostic testing, including laboratory specimen collection, imaging coordination, and biomarker analysis
- Treatment planning, clinical recommendations, and care coordination
- Prescribing medications, nutraceuticals, supplements, and compounded preparations as permitted by applicable law
- Administration of medications, injectable therapies, IV infusions, and other therapeutic agents
- Performance of procedures, recovery therapies, and technology-based wellness services
- Telehealth consultations and remote clinical oversight
This consent is general in nature. Specific high-risk procedures or treatments may require a separate, procedure-specific informed consent prior to administration. The existence of this general consent does not substitute for procedure-specific disclosure where required by law or clinical best practice.
Next Health operates in compliance with Corporate Practice of Medicine doctrine and applicable laws governing the professional independence of licensed healthcare providers. You understand and acknowledge that:
- All clinical decisions - including diagnosis, treatment planning, prescribing, ordering of tests, and clinical recommendations - are made solely by licensed healthcare professionals exercising their independent professional judgment.
- Next Health corporate personnel, franchise owners, management staff, administrative personnel, and non-clinical employees do not direct, override, or interfere with clinical decisions made by licensed providers.
- Business, operational, or financial considerations do not govern the clinical care you receive. Your provider's recommendations are based on your individual health needs and clinical evidence.
- Next Health's business structure is designed to support - not control - the professional practice of medicine. Licensed providers retain full clinical autonomy over patient care decisions.
YOUR PROVIDER IS INDEPENDENT:
The licensed provider caring for you at Next Health makes all clinical decisions based on your health and their professional judgment - not on instructions from corporate, management, or non-clinical staff. If you ever have concerns about the independence of your care, you have the right to raise them directly with your provider or Next Health's Medical Director.
Next Health is committed to ensuring meaningful access to care for all patients, regardless of primary language or communication ability. In accordance with Title VI of the Civil Rights Act of 1964 and applicable federal healthcare non-discrimination requirements:
- If English is not your primary language, or if you require communication assistance due to a disability, Next Health will make reasonable efforts to provide language assistance at no cost to you.
- Next Health utilizes electronic automated translation applications and interpretation services to facilitate communication in languages other than English. These tools are provided to assist you in understanding your care; however, you have the right to request a qualified human interpreter for clinical conversations involving diagnosis, treatment decisions, or informed consent.
- Translated materials and language assistance are available upon request. Please notify a staff member of your language preference or communication needs before services begin.
- Do not sign this or any Next Health consent form until you are confident you understand it in your preferred language. If you need assistance understanding this document, please ask before signing.
If you need language assistance, please tell a staff member before signing any form or receiving any service. Language assistance is available at no cost to you.
You have the right to know the identity and professional qualifications of the healthcare providers involved in your care at Next Health. You understand and acknowledge that:
- You may request the name, professional credentials, and role of any provider treating you at any time, and Next Health will provide this information promptly.
- Some services at Next Health may be performed by non-physician practitioners - including nurse practitioners (NPs), physician assistants (PAs), and registered nurses (RNs) - operating under physician supervision or collaborative practice agreements as permitted by applicable state law.
- You may request information about the supervision or collaboration arrangements governing your care at any time.
- If students, trainees, or clinical observers will be involved in your care in any capacity, you will be informed in advance and your consent will be obtained before their participation.
- You have the right to request that only licensed, credentialed providers participate in your care, and this request will be accommodated to the extent operationally possible.
Next Health is not acting as your Primary Care Provider ("PCP"). You agree to:
- Maintain an ongoing relationship with a licensed PCP.
- Share relevant test results and clinical recommendations with your PCP and other treating providers as appropriate.
- Be responsible for sharing relevant test results and recommendations with your PCP and obtaining medical clearance when required before initiating significant treatment, medication, supplement, dietary, or lifestyle changes outside of those directly managed by Next Health.
- Authorize Next Health to obtain relevant medical records, laboratory results, imaging studies, and clinical documentation from outside providers upon your request and execution of appropriate HIPAA-compliant authorizations. You understand that Next Health will not obtain outside records without your written authorization.
- Consult your PCP or appropriate specialist before making significant medical or lifestyle changes when such consultation is clinically advisable.
If you do not currently have a PCP, you are encouraged to establish one. Next Health providers will assist with care coordination as clinically appropriate regardless of your PCP status.
You understand that all medical, wellness, diagnostic, and technology-based services involve known and unknown risks. Potential risks include, but are not limited to:
- Bruising, bleeding, pain, or discomfort at treatment sites
- Infection or inflammatory response
- Allergic reactions, including severe or anaphylactic reactions
- Medication side effects or adverse drug interactions
- Electrolyte imbalance or metabolic disturbances
- Diagnostic inaccuracies, false-positive or false-negative results
- Delayed diagnosis or missed diagnosis
- Injury
- Serious medical complications
- Death
You acknowledge that medicine is not an exact science and that no guarantees or warranties regarding outcomes have been made. You voluntarily assume the inherent risks associated with the services you receive.
We encourage you to involve a caregiver, family member, or trusted person who can help monitor for delayed reactions and report any significant changes in your symptoms or condition after treatment, particularly following injectable, infusion, or procedure-based services.
You authorize the collection of blood, urine, saliva, stool, sputum, cheek swab, breath, finger-stick, genetic, microbiome, and other diagnostic specimens as medically appropriate. You understand that:
- Samples are analyzed by independent third-party laboratories not under the direct control of Next Health.
- Delays, specimen loss, processing errors, and inaccurate results may occur.
- Next Health cannot guarantee laboratory performance, turnaround times, or result accuracy.
- Your protected health information ("PHI") will be shared with laboratories only as necessary for testing, reporting, and coordination purposes under applicable HIPAA business associate agreements.
- All testing fees are non-refundable once testing has been performed, regardless of results.
- Fees include specimen collection, coordination, processing, interpretation, and related clinical review services.
Bloodwork review services provided by Next Health constitute clinical guidance and education. You understand that:
- These services do not establish an ongoing physician-patient treatment relationship unless a separate treatment agreement has been executed.
- Recommendations provided are not treatment orders and must not replace the guidance of your PCP.
- You are encouraged to share recommendations with your PCP and other treating providers as appropriate.
Cash-Pay / Self-Pay Laboratory Services Acknowledgment
All laboratory testing ordered through Next Health is provided on a self-pay, cash-pay basis. By accepting lab services, you acknowledge and agree to all of the following:
- Self-pay basis: All laboratory tests and services ordered through Next Health are provided on a self-pay, cash-pay basis. These services will not be billed to, and will not be submitted for reimbursement to, Medicare, Medicaid, or any commercial health insurance plan by Next Health, its affiliated laboratories, or any third-party vendor involved in processing your tests.
- No personal insurance submission: You agree not to personally submit any Next Health lab charge, invoice, or related documentation to your health insurance company, Medicare, Medicaid, or any other third-party payor for reimbursement. You understand that you are solely responsible for the full cost of all laboratory services.
- HSA / FSA / HRA payments permitted: You may pay for laboratory services using funds from a Health Savings Account (HSA), Flexible Spending Account (FSA), or Health Reimbursement Arrangement (HRA) if you have one. Payment via these accounts is a form of direct payment using your own account funds and does not change the cash-pay nature of this transaction. Next Health may provide a standard receipt for account substantiation purposes; this receipt is not an insurance claim and should not be submitted as one.
- Medicare / Medicaid enrollment: If you are currently enrolled in Medicare or Medicaid, please notify a Next Health staff member before proceeding with any laboratory order. Additional documentation - including an Advance Beneficiary Notice (ABN) where applicable - may be required before services can be rendered.
- Voluntary agreement: You are entering into this cash-pay agreement voluntarily. You have had the opportunity to ask questions about the self-pay nature of these services before signing.
IMPORTANT - LABORATORY BILLING POLICY:
Next Health laboratory services are CASH-PAY ONLY. They will not be submitted to Medicare, Medicaid, or any health insurance plan. You agree not to submit these charges to insurance yourself. HSA/FSA/HRA payment is permitted.
If you are a Medicare or Medicaid beneficiary, please notify staff before any lab order is placed.
Intravenous ("IV"), intramuscular ("IM"), and injectable therapies involve the administration of nutrients, medications, hydration solutions, and other therapeutic agents directly into the body. You understand the following risk categories:
Common Risks:
- Pain, bruising, discomfort, or swelling at or near the injection or infusion site
Less Common Risks:
- Phlebitis (vein inflammation)
- Localized infection
- Nerve injury
- Electrolyte imbalance
Rare but Serious Risks:
- Severe allergic reaction or anaphylaxis
- Cardiac arrhythmia or cardiac complications
- Hospitalization
Potential benefits may include enhanced nutrient delivery, improved hydration, improved recovery, and other wellness objectives. You acknowledge that individual outcomes vary and no specific benefit is guaranteed.
Next Health may offer certain services that carry additional regulatory, clinical, or safety considerations. Your provider will review service-specific risks with you prior to treatment. The following services require specific acknowledgment:
a. Peptide Therapy
Certain peptides are compounded medications subject to FDA compounding regulations. Availability may change based on regulatory guidance (see also Section 16, Compounded Medications). Off-label and investigational use is possible. Risks include injection site reactions, hormonal or metabolic effects, and unknown long-term effects.
b. Hormone Replacement Therapy (HRT) / Testosterone Replacement Therapy (TRT)
Hormone therapies carry risks including cardiovascular effects, changes in blood counts, mood changes, fertility effects, and potential for dependency. Baseline and follow-up laboratory monitoring is required. These therapies are contraindicated in certain conditions and require a Next Health medical provider consultation prior to initiation.
c. Hyperbaric Oxygen Therapy (HBOT)
HBOT involves breathing 100% oxygen at increased atmospheric pressure. Medical clearance is required prior to participation. Risks include:
- Ear barotrauma (ear pain, pressure, or damage due to pressure changes)
- Sinus barotrauma (sinus pain or injury due to pressure changes)
- Pulmonary barotrauma or pneumothorax (lung injury; contraindicated with untreated pneumothorax)
- Oxygen toxicity, which may cause visual disturbances, dizziness, or, in rare cases, seizure
- Confinement anxiety or claustrophobia-related distress
- Temporary vision changes (myopia) with extended treatment courses
- Fire hazard (all flammable materials are prohibited inside the chamber)
HBOT is contraindicated in patients with untreated pneumothorax, certain pulmonary conditions, recent ear surgery, active upper respiratory infection, certain cardiac conditions, and during pregnancy. A Good Faith Exam evaluation is required before your first session.
d. Transcranial Magnetic Stimulation / Cognitive Technologies
Non-invasive brain stimulation technologies are generally considered safe but may cause headache, scalp discomfort, or, rarely, seizure. These technologies are not FDA-cleared for all intended uses described in wellness contexts.
e. Platelet-Rich Plasma (PRP) & Regenerative Therapies
PRP and related regenerative therapies use your own blood or biological materials processed and re-administered. Risks include injection site reactions, infection, and variable or no clinical response. Evidence for efficacy in wellness contexts is emerging and not universally established.
f. Cellular & Exosome Therapies
Next Health does not use, administer, or refer to any product as a "stem cell therapy" in public-facing or patient communications. Certain biological therapies derived from cellular or exosome-based products may be offered. These therapies are investigational, not FDA-approved for the purposes described, and carry risks including immune reaction, unknown long-term safety profile, and variable outcomes. A separate service-specific disclosure will be provided prior to any such treatment.
g. Product & Therapy Availability
Certain medications, compounded preparations, peptides, biologics, diagnostics, and technologies offered by Next Health may become unavailable or undergo pricing changes due to:
- Manufacturer shortages or supply chain disruptions
- Regulatory changes, FDA guidance updates, or compounding pharmacy restrictions
- Changes in applicable state or federal law
- Formulary or sourcing decisions made by Next Health or its pharmacy partners
Next Health does not guarantee continued access to any specific product, therapy, medication, or technology. If a therapy you are currently receiving becomes unavailable, your provider will discuss alternative options with you.
You understand that medications prescribed or administered by Next Health may be used for indications, dosing regimens, combinations, or treatment objectives that differ from FDA-approved labeling. Off-label use of FDA-approved medications is a lawful, common, and clinically accepted practice in medicine. You acknowledge that:
- Off-label use means the medication is being used in a manner not specifically reviewed or approved by the FDA for that indication, dose, patient population, or combination.
- Off-label use does not mean the medication is unsafe or experimental; however, the evidence base supporting off-label use varies by medication and indication.
- Your Next Health provider has determined that the off-label use is clinically appropriate for your individual health goals and has considered the available evidence in making this recommendation.
- You have the right to ask your provider for information about any off-label use - including the evidence supporting it and any alternatives - before consenting to treatment.
- Off-label medications may not be covered by insurance and are your financial responsibility.
- You are encouraged to talk to your primary care provider to get additional information about off-label medication use.
Next Health may prescribe or administer medications that are compounded by licensed outsourcing facilities or compounding pharmacies operating under applicable state and federal law, including Section 503A and 503B of the Federal Food, Drug, and Cosmetic Act. You understand and acknowledge that:
- Compounded medications are not reviewed or approved by the U.S. Food and Drug Administration (FDA) for safety, effectiveness, or manufacturing consistency in the same manner as commercially manufactured, FDA-approved drug products.
- Compounded medications are prepared based on a licensed prescriber's order and are intended to meet an individual patient's specific clinical need that cannot be met by an available commercial product.
- The FDA does not verify the potency, purity, sterility, or stability of compounded preparations.
- Compounded medications may include peptides, hormones, vitamins, amino acids, and other bioactive compounds used in longevity and functional medicine protocols.
- The availability of specific compounded preparations may change due to regulatory guidance, FDA enforcement actions, or pharmacy sourcing limitations without advance notice.
- You have the right to ask your provider for information about any compounded medication before it is administered.
FDA COMPOUNDING NOTICE:
Compounded drugs are not FDA-approved. This means the FDA has not verified their safety or effectiveness. Ask your Next Health provider if you have questions about any compounded medication in your protocol.
Next Health may recommend, dispense, or administer dietary supplements, nutraceuticals, vitamins, minerals, herbal preparations, botanical extracts, and related wellness products. You understand and acknowledge that:
- Dietary supplements and nutraceutical products are evaluated as food products, not drugs. They are not generally reviewed or approved by the FDA for the diagnosis, treatment, cure, or prevention of any disease or medical condition.
- The FDA does not evaluate supplement products for safety or efficacy before they are marketed. Manufacturers are responsible for ensuring their products are safe, but pre-market FDA approval is not required.
- Individual responses to dietary supplements vary significantly. No specific outcome - including symptom improvement, laboratory value changes, weight loss, body composition changes, cognitive enhancement, or energy improvement - is guaranteed.
- Certain supplements may interact with prescription medications, affect laboratory test results, or be contraindicated in specific medical conditions. Always inform your Next Health provider and your PCP of all supplements you are taking.
- Supplements recommended or sold by Next Health, including those offered under Next Health's own branded product lines, are subject to the same limitations described above.
Certain medications, supplements, injectable therapies, biologics, peptides, hormones, nutraceuticals, and other treatments provided, prescribed, recommended, or administered by Next Health may be contraindicated during pregnancy, breastfeeding, attempts to conceive, or certain reproductive health conditions.
You acknowledge that exposure to certain substances during pregnancy or breastfeeding may pose known or unknown risks to a fetus, embryo, nursing infant, reproductive function, fertility, pregnancy outcomes, or long-term child development. Examples of medications that may carry specific reproductive risks include:
- Ketorolac (generic: ketorolac tromethamine; brand: Toradol) - may be contraindicated during pregnancy, breastfeeding, impaired fertility, kidney disease, gastrointestinal disorders, and bleeding disorders.
- Ondansetron (generic: ondansetron; brand: Zofran) - has been associated with potential fetal risks and requires careful consideration during pregnancy.
These examples are illustrative and do not represent a complete list. You agree to immediately inform Next Health of any current or suspected pregnancy, plans to become pregnant, fertility treatments, breastfeeding status, or changes in reproductive status before receiving any treatment or service.
By consenting to cryotherapy, infrared LED sauna, or related recovery technology services, you certify that none of the following contraindications currently apply to you:
- Recent cardiac event or unstable cardiovascular condition
- Congestive heart failure
- Implanted pacemaker or defibrillator
- Active cancer (undergoing active treatment)
- Active systemic infection or fever
- Raynaud's disease or cold sensitivity disorders
- Deep vein thrombosis or history of pulmonary embolism
- Current pregnancy or breastfeeding
- Severe claustrophobia
You agree to immediately notify staff if any of the above conditions develops or if your medical status changes prior to a session.
Next Health may capture clinical photographs, video recordings, and audio recordings during in-person treatment or telehealth encounters for the sole purpose of clinical documentation. Permitted clinical uses include:
- Medical charting and maintaining an accurate medical record
- Treatment planning, progress tracking, and outcome monitoring (e.g., body composition imaging, skin analysis, pre/post procedure documentation)
- Clinical consultation, specialist referral coordination, or second-opinion review
- Telehealth session recording for clinical continuity and documentation purposes
- Quality assurance review and clinical training within Next Health's licensed care team
Clinical photographs, videos, and audio recordings made for documentation purposes are treated as part of your medical record and are subject to the same confidentiality and HIPAA protections as all other PHI. You may request access to clinical recordings of yourself as part of your medical record request.
IMPORTANT:
Clinical documentation consent does NOT authorize use of your image, voice, or likeness for marketing, advertising, social media, or any commercial purpose. Such use requires your separate voluntary authorization under Section 22 below.
Your consent to clinical photography and video documentation is a condition of receiving certain services where visual or audio documentation is a clinical standard of care. You may withdraw this consent in writing for future sessions, though withdrawal may affect Next Health's ability to provide certain services that require documented visual or audio records.
Next Health facilities may utilize audio, video, security, and environmental monitoring systems throughout treatment areas, common areas, hallways, reception, and other facility spaces. You understand and acknowledge that:
- Monitoring systems may be in use for purposes including patient and staff safety, quality assurance, security, clinical training, incident investigation, regulatory compliance, and facility operations. Monitoring may occur in treatment areas for patient safety and quality assurance purposes.
- Facility monitoring is passive and facility-wide in nature. It is not intended to provide continuous medical observation, clinical supervision, or emergency response capability.
- Facility monitoring systems do not substitute for emergency services. If you experience a medical emergency, call 911 or notify staff immediately (see Section 29).
- Audio and video recordings captured by facility monitoring systems are treated as confidential business and security records. They are not part of your medical record unless specifically incorporated following a documented clinical incident.
- Access to facility monitoring recordings is restricted to authorized Next Health personnel and, where required, law enforcement or regulatory authorities pursuant to applicable legal process.
NOTICE:
By entering Next Health facilities, you acknowledge the presence of facility monitoring systems as described above. Monitoring in clinical treatment rooms is conducted only to the extent operationally and clinically necessary, and in compliance with applicable privacy law and applicable HIPAA requirements.
Separate from and in addition to clinical documentation, Next Health may request your voluntary authorization to capture photographs, video recordings, or audio recordings for marketing, media, educational, or promotional purposes. You understand that:
- No compensation will be provided unless separately agreed upon in writing prior to the recording session.
- Recordings may be used for educational, informational, training, advertising, digital media, social media, broadcast, or other institutional and commercial purposes.
- You may revoke this marketing consent in writing at any time. Revocation will not affect recordings already produced and lawfully published prior to receipt of your written revocation.
- Declining will not affect care.
You authorize Next Health to communicate with you through email, SMS/text messaging, secure messaging platforms, and telehealth platforms. You understand that these methods may involve security risks, and that unauthorized third parties could potentially access communications despite reasonable safeguards.
SMS/Text Message Program - Required Disclosures (TCPA):
- By providing your mobile telephone number, you expressly consent to receive recurring automated text messages from Next Health at the number provided.
- Message types include: appointment reminders, clinical notifications, health tips, and promotional or marketing messages related to Next Health services.
- Message frequency: Up to 8 messages per month. Frequency may vary.
- Standard message and data rates may apply. Contact your carrier for details.
- To stop receiving messages, reply STOP at any time. You will receive a one-time confirmation and no further messages will be sent.
- For help, reply HELP or contact us at the information on our website.
- Consent to receive marketing messages is NOT a condition of receiving any Next Health service or of purchasing any goods or services.
You may opt out of marketing messages only while continuing to receive appointment and clinical notifications by contacting Next Health directly.
You understand that most Next Health services are elective and not covered by health insurance. You acknowledge that:
- You are solely responsible for all charges incurred at the time of service.
- Submission of insurance claims does not guarantee reimbursement.
- Non-covered services remain your financial responsibility regardless of insurance status.
- Membership, subscription, and program fees are governed by the applicable membership agreement, which is incorporated by reference.
- Cancellation, no-show, and late-cancellation policies are set forth in the Membership and Service Agreement provided to you at enrollment. Fees may apply.
- You remain financially responsible for medical evaluation, treatment, hospitalization, specialist consultation, or emergency services required as a result of complications arising from participation in Next Health services, except where prohibited by applicable law.
FEDERAL NO SURPRISES ACT - GOOD FAITH ESTIMATE (42 U.S.C. § 300gg-132):
You have the right to receive a Good Faith Estimate ("GFE") of expected charges before any scheduled service. Next Health will provide a written GFE at least 3 business days before any scheduled service (or at least 1 business day if scheduled within 3 days).
If your final bill is $400 or more above the Good Faith Estimate you received, you may dispute the charge through the federal patient-provider dispute resolution process.
To request a Good Faith Estimate, or to dispute a charge, contact: accounting@next-health.com
By signing this form, you confirm that you have either received a Good Faith Estimate for today's services or have been offered one and chosen to proceed.
Membership fees, subscription fees, and recurring program fees provide access to designated services, benefits, educational resources, discounts, or wellness offerings as described by Next Health. You acknowledge that:
- Memberships do not guarantee specific health outcomes or medical improvement.
- Memberships do not create an ongoing physician-patient relationship unless separately established in writing.
- Membership benefits, pricing, and included services may be modified in accordance with your membership terms and conditions, with advance notice as required by applicable law.
- You remain responsible for all services rendered that are not included within your membership benefits.
Your appointment and cancellation obligations are governed by the Membership and Service Agreement provided to you at enrollment. Key provisions are summarized below:
- Late cancellations (within 24 hours of a scheduled appointment) and no-shows may be subject to a fee as set forth in your Membership Agreement.
- Certain prepaid services that are cancelled without adequate notice may be forfeited in accordance with the applicable service terms. Your right to cancel a membership or subscription and receive a prorated refund is governed by applicable state law and the terms of your Membership Agreement.
Certain Next Health services may be delivered through telemedicine technologies, including video conferencing, audio communication, secure messaging, remote monitoring devices, mobile applications, and other electronic communication platforms. You understand that:
- Telehealth services may involve limitations including technology failures, transmission interruptions, reduced ability to perform physical examinations, cybersecurity risks, and delays in evaluation or treatment.
- Telehealth services may not be appropriate for all medical conditions, and in-person care may be recommended when clinically appropriate.
- Prescribing of medications via telehealth is subject to applicable federal and state law, including the Ryan Haight Online Pharmacy Consumer Protection Act (21 U.S.C. § 831) and California Business & Professions Code § 2242.1. Certain controlled substances may not be prescribed via telehealth without a prior in-person evaluation.
- You consent to the use of telehealth technologies for evaluation, consultation, education, monitoring, and communication related to your care.
Certain Next Health services may be contraindicated in patients with active cancer, recent chemotherapy, recent radiation therapy, or ongoing oncology treatment. You understand and acknowledge that:
- If you have been diagnosed with cancer or are currently receiving oncology treatment (including chemotherapy, radiation, immunotherapy, or targeted therapy), you must disclose this to your Next Health provider before receiving any service.
- Services including but not limited to cryotherapy, HBOT, hormone therapies, peptide protocols, IV therapies, and certain nutraceutical programs may require additional written clearance from your oncologist or treating physician before Next Health can provide them.
- Next Health reserves the right to postpone or decline services for patients with active cancer or recent oncology treatment until appropriate medical clearance is obtained.
- This requirement is not intended to restrict access to supportive wellness services that may complement your oncology care, but rather to ensure that all treatments are safe and appropriate given your specific oncology history and current treatment status.
If you have a history of cancer but are not currently in active treatment, please disclose this to your provider at intake so your care plan can be appropriately tailored.
Next Health does not provide emergency medical services. If you experience a medical emergency, you must immediately call 911 or go to the nearest emergency room. Medical emergencies include but are not limited to:
- Chest pain or pressure
- Difficulty breathing or shortness of breath
- Signs or symptoms of stroke (sudden facial drooping, arm weakness, speech difficulty)
- Loss of consciousness
- Suicidal ideation or self-harm crisis
- Severe injury or uncontrolled bleeding
Electronic communications with Next Health - including email, SMS, and secure messaging - are NOT monitored for emergency response purposes. Do not use these channels to report a medical emergency.
POST-TREATMENT ADVERSE EVENT REPORTING:
If you experience any adverse reaction, unexpected symptom, or significant change in your health after treatment - even if you are unsure whether it is related to your care - you agree to contact Next Health within 48 hours (or sooner for urgent concerns).
24/7 Clinic Contact Line: (310) 295-2075
When seeking emergency care, please inform any emergency provider about all treatments and medications you have received at Next Health.
Laboratory testing, imaging, genetic testing, cancer screening, microbiome testing, biomarker assessments, wearable device data, and other diagnostic evaluations have inherent limitations. You acknowledge that:
- No test is 100% accurate.
- False-positive and false-negative results may occur and may lead to unnecessary treatment or missed diagnosis.
- Normal results do not guarantee the absence of disease.
- Risk assessments and predictive models do not guarantee future health outcomes.
- No screening or testing program can detect all diseases or medical conditions.
All diagnostic findings should be reviewed with your PCP to determine appropriate follow-up.
Consumer Health Technologies & Wearable Device Data
Next Health may review or incorporate data obtained from consumer-grade wearable devices, mobile health applications, continuous glucose monitors, and other third-party health platforms (such as Oura, WHOOP, Apple Health, Dexcom, and similar services). You understand and acknowledge that:
- Consumer health device data may be incomplete, delayed, inaccurate, uncalibrated, or temporarily unavailable due to device limitations, synchronization errors, or platform outages.
- Consumer devices are not FDA-cleared medical devices in most configurations, and the data they generate is not equivalent to clinical diagnostic testing.
- Wearable and consumer health data should not be relied upon as the sole basis for any diagnosis, treatment decision, or medication adjustment.
- Next Health is not responsible for the accuracy, completeness, security, or availability of data generated by third-party consumer devices or platforms.
- Digital twin models and longitudinal health dashboards that incorporate consumer device data are analytical tools intended to supplement, not replace, clinical evaluation.
If you share consumer device data with Next Health, you authorize its use in your clinical record and wellness planning, subject to the privacy protections described in Section 33.
Next Health may utilize artificial intelligence ("AI"), machine learning systems, predictive analytics, algorithmic risk assessments, digital twin technologies, clinical decision-support tools, and other advanced technologies in connection with your care. You acknowledge that:
- Such technologies are intended to supplement, not replace, professional medical judgment.
- AI-generated recommendations may contain inaccuracies, omissions, limitations, or biases inherent in the underlying models and datasets.
- Healthcare decisions should not be based solely upon AI-generated information.
- Final clinical decisions remain the responsibility of licensed healthcare professionals and you as the patient.
You consent to the use of such technologies as part of Next Health's services.
If you elect to undergo genetic testing, you understand that genetic testing may reveal information regarding inherited disease risk, medication response, carrier status, ancestry, or other genetic traits. You further understand that:
- Results may have implications for biological relatives who have not consented to testing.
- Results may create emotional, psychological, financial, insurance, or employment concerns, despite legal protections under the Genetic Information Nondiscrimination Act (GINA) (and California Genetic Information Nondiscrimination Act (CalGINA) if care is provided in California).
- Genetic testing cannot predict with certainty whether a disease or condition will develop.
- Future scientific discoveries may alter the interpretation of current genetic findings.
Participation in genetic testing is entirely voluntary. You may decline genetic testing without affecting your right to receive other Next Health services.
You acknowledge receipt of, or access to, Next Health's Notice of Privacy Practices ("NOPP"), which describes how your Protected Health Information ("PHI") may be used and disclosed for treatment, payment, healthcare operations, and other purposes permitted by HIPAA.
You understand that:
- Next Health reserves the right to amend its Notice of Privacy Practices, and updated versions will be made available in accordance with applicable legal requirements.
- You have the right to request access to, amendment of, and an accounting of disclosures of your PHI, subject to applicable legal limitations.
- California residents have additional rights under the California Confidentiality of Medical Information Act (CMIA) and the California Consumer Privacy Act ("CCPA") / California Privacy Rights Act ("CPRA"), including the right to know, right to delete, and right to correct personal information. See our Privacy Policy at www.next-health.com/privacy.
- PHI may be shared with independent laboratories, telehealth platforms, and other service providers as necessary to provide care, pursuant to executed HIPAA Business Associate Agreements.
You authorize Next Health to collect, analyze, aggregate, use, and disclose de-identified health information in accordance with applicable law, including the HIPAA de-identification safe harbor standard (45 C.F.R. § 164.514). De-identified information may be used for:
- Quality improvement initiatives, outcomes analysis, and clinical performance benchmarking
- Maintenance of longitudinal health outcomes registries and quality-improvement databases
- Population health studies and longevity research programs
- Product and service development
- Clinical research, scientific publications, and peer review submissions
- Educational activities and professional training
- Artificial intelligence and machine learning model development and validation
OUTCOMES REGISTRY NOTICE:
Next Health may maintain de-identified outcomes registries and longitudinal health datasets to support research, publish population health findings, and improve clinical programs. Your data, once de-identified per HIPAA standards, may be included in these registries. This does not reveal your identity and is not subject to withdrawal once incorporated into aggregated datasets.
De-identified information does not include your personal identifiers and is not intended to reveal your identity. You may not withdraw this authorization with respect to information that has already been de-identified and incorporated into aggregate datasets, as technical reversal is not feasible.
You consent to receiving communications from Next Health through email, SMS/text messaging, secure messaging platforms, telehealth applications, and other electronic systems. Such communications may include laboratory results and imaging reports, clinical recommendations and care summaries, electronic prescriptions, appointment reminders, billing communications, membership information, educational materials, and program updates.
You acknowledge that electronic communications may involve privacy and security risks despite reasonable safeguards and accept such risks as a condition of utilizing these communication methods.
Next Health is built on a philosophy of prevention, optimization, performance, recovery, and healthy aging. Our clinical programs are designed to identify risk factors earlier, improve quality of life, support healthy behaviors, and promote long-term health outcomes - before disease develops, not after. You understand that:
- Many Next Health services are proactive and anticipatory in nature, targeting the underlying drivers of aging, metabolic dysfunction, and chronic disease risk rather than treating established illness.
- Participation in Next Health programs is intended to support your health journey and long-term wellbeing. It should not be interpreted as a guarantee of disease prevention, lifespan extension, reversal of aging, or any specific health outcome.
- The science of longevity medicine is advancing rapidly. Some protocols and recommendations are based on emerging evidence that may evolve over time as research matures.
- Individual results vary based on genetics, lifestyle, adherence, baseline health status, and many other factors outside Next Health's control.
No guarantees regarding health improvement, disease prevention, longevity, or lifespan extension have been made to you. More specifically, no guarantee is made regarding symptom improvement, laboratory value improvement, body composition changes, cognitive performance, athletic performance, fertility, weight loss, disease prevention, or any other clinical outcome. Next Health's mission is to provide the highest-quality evidence-informed care - the outcome of that care depends on many factors unique to each patient.
TERMINOLOGY NOTICE:
Terms such as "longevity," "health optimization," "age reversal," "biological age," "healthspan," and similar concepts as used by Next Health are educational or aspirational in nature. They should not be interpreted as guarantees of increased lifespan, disease prevention, reversal of the aging process, or any specific measurable health outcome.
Next Health continuously evaluates, develops, and introduces new wellness technologies, diagnostic tools, therapeutics, medications, devices, software platforms, digital health programs, and clinical protocols. You understand and agree that:
- This consent covers participation in current Next Health services and, to the extent applicable, services or enhancements introduced during your membership or treatment relationship that are consistent in nature with what is described herein.
- Additional service-specific disclosures, procedure-specific informed consents, or supplemental acknowledgments may be required before you participate in any newly introduced therapy, technology, or clinical program.
- The introduction of a new service does not automatically constitute a material change requiring re-execution of this entire document, provided that service-specific disclosure is obtained where required by law or clinical best practice.
- You will be notified of any material changes to this general consent form that affect your existing rights, and you will have the opportunity to review and re-sign an updated version.
This clause ensures that Next Health's master consent remains valid and current as new services are launched, without requiring a complete re-consent for every protocol update. Service-specific consents will be obtained separately for high-risk or novel therapies.
Next Health providers may not have access to all medical records, specialist reports, emergency department records, imaging studies, operative reports, medication histories, or health information from outside healthcare providers or health systems. You understand and acknowledge that:
- Clinical recommendations, treatment plans, and prescribing decisions made at Next Health are based on the information available at the time of evaluation, which may be incomplete if outside records have not been provided.
- You are responsible for providing complete, accurate, and current health information to your Next Health provider, including all current medications, supplements, recent diagnoses, prior surgeries, hospitalizations, and ongoing treatments by other providers.
- Failure to disclose relevant health information may affect the safety and appropriateness of services provided and may limit Next Health's ability to deliver appropriate care.
- You are encouraged to bring a current medication list, recent laboratory results, and relevant specialist notes to each visit to support comprehensive care coordination.
- Next Health is not responsible for clinical decisions made on the basis of incomplete information that you failed to disclose.
If you are being treated by other physicians, specialists, or healthcare providers concurrently with your Next Health care, please inform your Next Health provider. Comprehensive disclosure supports your safety and helps your providers avoid contraindicated treatments or drug interactions.
Before consenting to any Next Health service, you have the right to be informed of alternatives. Alternatives to services offered by Next Health may include, depending on the specific service:
- Observation and watchful waiting
- Lifestyle modification, including dietary changes, sleep optimization, and stress reduction
- Exercise programs and physical therapy
- Oral supplementation and nutritional interventions
- Conventional medical treatment by your primary care provider or specialist
- Referral to an appropriate medical specialist
- No treatment at all
Your Next Health provider will discuss applicable alternatives with you prior to initiating any treatment. For injectable and IV therapies specifically, oral supplementation and lifestyle modification represent common alternatives that you may wish to discuss with your provider. You have the right to ask questions about alternatives at any time and to decline any service without penalty to your ongoing care.
To the fullest extent permitted by applicable state and federal law, and specifically with respect to the inherent and voluntary risks of elective wellness and preventive health services described in this document, you voluntarily assume those inherent risks and release, waive, and discharge Next Health and its affiliated entities, providers, employees, contractors, officers, directors, franchisees, and representatives from claims arising directly from your voluntary, informed participation in such elective services. Nothing in this section limits your rights under applicable state law.
To the extent this document operates as a release, you expressly waive all rights and benefits under California Civil Code Section 1542, which provides:
"A general release does not extend to claims that the creditor or releasing party does not know or suspect to exist in his or her favor at the time of executing the release and that, if known by him or her, would have materially affected his or her settlement with the debtor or released party."
- California Civil Code § 1542
You acknowledge that this waiver is knowing and voluntary, that you have had the opportunity to consult with counsel, and that it applies only to the inherent-risk release described in Section 40, subject to the limitations stated therein.
You knowingly and voluntarily waive your right to a jury trial for any dispute arising out of or related to services provided by Next Health. You further agree that any claims shall be brought solely in your individual capacity and not as part of any class action, collective action, or representative action proceeding.
California Patients - Please Read:
Under California law, certain class action and representative action rights (including under the Private Attorneys General Act / PAGA) may not be waivable. Nothing in this section is intended to waive any right that is non-waivable under California law. This section should be confirmed by California healthcare and employment counsel before enforcement.
NOTICE: BINDING ARBITRATION AGREEMENT
The following section contains an agreement to arbitrate disputes. By signing this document, you are agreeing to resolve most disputes with Next Health through binding arbitration rather than in court.
You have the right to consult an attorney before signing. You may also request a separate Arbitration Agreement document if you wish to sign only the arbitration provision independently.
ARTICLE 1: NOTICE OF ARBITRATION
IT IS UNDERSTOOD THAT ANY DISPUTE AS TO MEDICAL MALPRACTICE, THAT IS AS TO WHETHER ANY MEDICAL SERVICES RENDERED UNDER THIS CONTRACT WERE UNNECESSARY OR UNAUTHORIZED OR WERE IMPROPERLY, NEGLIGENTLY, OR INCOMPETENTLY RENDERED, WILL BE DETERMINED BY SUBMISSION TO ARBITRATION AS PROVIDED BY STATE LAW, AND NOT BY A LAWSUIT OR RESORT TO COURT PROCESS, EXCEPT AS STATE LAW PROVIDES FOR JUDICIAL REVIEW OF ARBITRATION PROCEEDINGS. BOTH PARTIES TO THIS CONTRACT, BY ENTERING INTO IT, ARE GIVING UP THEIR CONSTITUTIONAL RIGHT TO HAVE ANY SUCH DISPUTE DECIDED IN A COURT OF LAW BEFORE A JURY, AND INSTEAD ARE ACCEPTING THE USE OF ARBITRATION.
Subject to the statutory notice above, and to the extent permitted by applicable state and federal law, any dispute, claim, or controversy arising out of or relating to services provided by Next Health - including claims for professional negligence, breach of contract, fraud, or statutory violations - shall be resolved exclusively through binding arbitration administered by JAMS pursuant to its applicable rules, except as follows:
- Small claims court: Either party may elect to bring an individual claim in small claims court for disputes within that court's jurisdictional limits.
- Emergency or provisional relief: Either party may seek emergency injunctive or provisional relief from a court of competent jurisdiction to prevent irreparable harm pending arbitration.
- Non-waivable claims: Nothing in this section waives any claim that cannot be waived under state law.
The arbitration shall be conducted in the county in which you received services, or as mutually agreed. The arbitrator shall have authority to award all remedies available at law or in equity. The costs of arbitration shall be allocated as provided by the applicable arbitration rules, provided that Next Health shall bear any costs that would otherwise prevent you from pursuing a bona fide claim.
Governing Law: This Agreement and all services provided under it shall be governed by and construed in accordance with the laws of the state in which the applicable services were rendered, without regard to conflict-of-law principles. If any provision of this Agreement is determined to be invalid or unenforceable under applicable state law, such provision shall be modified and enforced to the maximum extent permitted by law, and the remaining provisions shall remain in full force and effect.
Article 2: You may revoke your agreement to arbitrate by sending written notice to Next Health within 30 days of signing this document. You do not have to sign this arbitration agreement to receive emergency care.
By signing below, you confirm and acknowledge that:
- You have carefully read this entire Consent, Waiver, Authorization, and Acknowledgment, or have had it read to you in a language you understand.
- You have had the opportunity to ask questions and have received satisfactory answers before signing.
- You understand the risks, benefits, alternatives, and limitations of the services offered by Next Health.
- You understand that medicine is not an exact science and that outcomes cannot be guaranteed.
- You voluntarily elect to participate in services provided by Next Health.
- You accept responsibility for all decisions made regarding your participation in Next Health services.
- You have been provided with Next Health's Notice of Privacy Practices.
- You consent to evaluation and treatment as described in Section 5.
- If any provision of this Agreement is inconsistent with applicable state law, the provision shall be interpreted and enforced to the maximum extent permitted by applicable law, and the remaining provisions shall remain in full force and effect.
BY SIGNING BELOW, YOU ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTAND, AND AGREE TO ALL SECTIONS OF THIS DOCUMENT, INCLUDING THE BINDING ARBITRATION AGREEMENT IN SECTION 43.
Version 7.0 | Next Health | www.next-health.com | Subject to review by applicable healthcare counsel | Confidential - Do Not Distribute Without Authorization.
