MEDICAL INTAKE FORM

MEDICAL INTAKE FORM
Name*
.
Sex*
Female
Male
Date of Birth*
E-mail*
* Must Be Valid Email To Receive Medical Records
Address*

Phone*
* Best Number To Contact You For Your Appointment
Emergency Contact*
.
Emergency Contact Phone*
Please Complete Medical Screening Below
CARDIAC DISEASE
Congestive Heart Failure*
Yes
No
Heart Attack*
Yes
No
Pacemaker in the last 6 Months*
Yes
No
NEUROLOGICAL
Seizures*
Yes
No
Epilepsy*
Yes
No
CIRCULATORY
Raynauds*
Yes
No
FEMALES ONLY
Pregnancy*
Yes
No
Breastfeeding*
Yes
No
OTHER
Chemotherapy*
Yes
No
Active Infection*
Yes
No
I Agree That All Of The Above Is Accurate*
I Agree
Allergies*
Significant Medical History*
Have you experienced any of the following symptoms of Monkeypox in the last 14 days?

  • Rash: firm, pimple-like lesions 
  • Body Aches
  • Fever
  • Headache
  • Sore Throat 
  • Swollen Lymph nodes
  • Flu-Like Symptoms
Yes
No
Have you been exposed to anyone who has tested positive or shown symptoms of Monkeypox in the last 14 days?*
Yes
No
CONSENT & WAIVER

This document is intended to serve as confirmation of informed consent for any type of procedure and services at Next Health.

Must be 18+ years of age. If you are over the age of 69, a Medical Clearance Form must be signed by your Primary Care Provider, clearing you for these services.

Cannot be pregnant, breastfeeding, or under the influence.

By signing below, you agree that you have informed the qualified staff members of any known allergies to drugs or other substances, of any past reactions to anesthetics or medications, all current medications and supplements that you are taking, and all of your medical history.

NEXT HEALTH COVID-19 SCREENING & CONSENT

This page is intended to serve as confirmation of informed consent for COVID-19 Immune Globulin, Rapid PCR, and Rapid Antigen Testing services at NEXT HEALTH.

I understand that NextHealth is providing a non-FDA approved blood test for COVID Antibodies, PCR nasal swab for molecular specific and antigen testing for rapid results which function under an FDA recognized EUA ( Emergency Use Authorization) for increased testing capability which are both recognized under high complex laboratory conditions and CLIA waived certifications.

I understand that the PCR nasal swab is an FDA approved test for the detection of COVID-19.

I understand that the lab cost includes a processing fee for all COVID testing to help cover the “cost” to Next Health which includes staff time for the blood draw and shipping/handling of the specimen, as well as interpretation and result reporting along with increased sanitation and personal protective equipment supplied to all staff. This fee does not include any subsequent medical care.

Next Health is not responsible for any medical care beyond providing you with the results of the test. If I have symptoms or require additional care, testing or follow up, I will seek out the guidance of my primary care provider, and I understand I am financially responsible for this. There are NO refunds or complimentary repeat tests offered. All tests must be paid for in full at the price quoted before each test is performed. I understand that all testing done at Next Health is not covered by insurance and I understand that if I submit an insurance claim for it, that I will be responsible for any and all non-covered services.

By signing below, I agree that I have accurately informed the Next Health staff members of my medical history, any known allergies to medications, all current medications and supplements that I am taking, and any other relevant information to my care.   I am also responsible to share my results with my PCP and obtain advice from my PCP for any further treatment, procedures, diet changes, or lifestyle change, supplement or medicine change, or any change I decide to make whatsoever. I acknowledge that Next Health, Registered Nurses, Nurse Practitioners, and Physicians are not my primary medical provider. If I do not have a primary care provider, I will seek one out immediately.

I agree that I understand that I have been informed of the procedure of taking the blood specimen, and any feasible alternative options, and the risks and benefits as detailed as follows:
The procedure of a blood draw involves inserting a needle into a vein and drawing blood to send to a lab. This procedure may produce a local bruise, phlebitis, infection, or other local complication along with nasal irritation and or discomfort to obtain the needed specimen for the other testing methodology.  
During this process, there is a chance for delays, lost specimens, or incorrect results that are not the responsibility of Next Health.   I also understand that my personal results may be subject to reporting requirements of the study protocol, the CDC, or federal, state or local regulatory bodies.   I understand that my blood or other specimen will be sent off site to the respected laboratories testing facility, and my personal health information will be disclosed to the lab for identification purposes and if needed to the local health department and CDC for tracking.

I am aware that other unforeseeable complications could occur. I do not expect the Registered Nurses, Nurse Practitioners, Physicians, and/or other staff members to anticipate and/or explain all risks and possible complications.

I understand the risks and benefits and alternatives of the procedure and have had the opportunity to have all of my questions answered in terms and language that I can understand. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my informed consent.

I understand that an audio visual monitoring device is used throughout Next Health for safety purposes.

NEXT LABS: BLOOD / SPUTUM / URINE TESTS

You also agree that you understand that you have been informed of the procedure of taking the blood/urine/sputum specimen, and any feasible alternative options, and the risks and benefits.

The procedure of a blood draw involves inserting a needle into a vein and drawing blood to send to a lab. This procedure may produce a bruise, phlebitis, or other local complication.

Other lab testing procedures may be required, such as cheek swab for DNA, urine tests, stool tests, finger stick, breath test, etc.

I understand that the place performing the lab is a contracted lab company and specimens must be sent to them for analysis. During this process there is a chance for delays, lost specimens, or incorrect results that are not the responsibility of Next Health.

The blood or other specimen will be sent off-site, and my personal health information will be disclosed to the lab for identification purposes.

The fee that I am paying for the testing is the cost of the actual test (which may be a small portion of the total fee), the administration and coordination of handling the sample, the venipuncture or collection by an appropriate medical professional, test interpretation by a medical professional, and possibly additional follow-up.

There are NO refunds or complimentary repeat tests offered.  All tests must be paid for in full at the price quoted before each test is performed. If I require additional testing or follow-up, I will be financially responsible for these.                                   

I am responsible to share all results with my PCP and obtain clearance from my PCP for any further treatment, procedures, diet changes, or lifestyle change, supplement or medicine change, or any change I decide to make whatsoever.

I acknowledge that Next Health, Registered Nurses, Nurse Practitioners, and Physicians are not my primary medical provider. If I do not have a primary care provider, I will seek one out immediately.

I am aware that other unforeseeable complications could occur. I do not expect the Registered Nurses, Nurse Practitioners, Physicians, and/or other qualified staff members to anticipate and/or explain all risks and possible complications. If any complications do occur, it may require prolonged additional treatments that I will work with the professionals at Next Health to comply with. I will be financially responsible for the treatment of any and all complications.

I understand that all testing done at Next Health is not covered by insurance and I understand that if I submit an insurance claim for it, that I will be responsible for any and all non-covered services.

I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered in terms and language that I can understand.

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to lab testing with any different or further procedures which, in the opinion of my physician(s) and qualified staff members or others associated with this practice, may be indicated.

I understand that an audio visual monitoring device is used throughout Next Health for safety purposes.

PATIENT BLOODWORK REVIEW ACKNOWLEDGEMENT AND CONSENT

I request and consent to an evaluation by Next Health and its staff (collectively, “Practice”) of a certain laboratory test(s) run on my blood (“Bloodwork”). I wish to rely on Practice to exercise its professional judgment only in reviewing the results of my Bloodwork and making suggestions regarding healthcare services resulting from such results. I acknowledge, agree, and certify that:

1.    Practice is not my primary care provider.

2.    Practice’s only function as it relates to me is the review of my Bloodwork and related recommendations.

3.    Practice’s recommendations are not a treatment order and I will not treat them as such.

4.    It is solely my duty and responsibility to follow up with my primary care provider regarding my results and recommendations.

5.    As part of my follow up, I will share the results of my Bloodwork and Practice’s recommendations with my primary care provider.

6.    My primary care provider must review Practice’s results and recommendations, approve or modify the same, and develop a treatment plan for me.

7.    I will not act on the Bloodwork results or Practice recommendations without the involvement of my primary care provider.

I understand that Practice is not treating me and any questions I may have regarding my treatment, potential treatments, alternatives to such treatments, potential side-effects, and complications should be directed to my primary care provider. I further understand that if I desire for Practice to treat me, I must engage Practice separately and apparat from this Acknowledgement and Consent and complete the appropriate patient intake paperwork and assessment. I also understand that this Acknowledgement and Consent does not establish me as a patient of Practice and will not result in treatment by Practice.

I understand that the practice of medicine and surgery is not an exact science.  I further understand and accept that fees are paid for performance of medical services only, and not a guaranteed result. I acknowledge by my signature below that although a good outcome is expected, and a reasonable effort has been made to establish realistic expectations, there cannot be any warranty, expressed or implied, as to the results that may be obtained.

IV AND IM TREATMENTS

The procedure involves inserting a needle into a vein or muscle and injecting the prescribed solution intravenously.

Alternatives to intravenous therapy are oral supplementation and/or dietary and lifestyle changes.

Risks of intravenous therapy include but not limited to:
Occasionally to commonly - discomfort, bruising, pain at the site of injection.  Rarely - inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury. Extremely Rarely - Severe allergic reaction, anaphylaxis, infection, cardiac arrest, and death.

Benefits of intravenous therapy include:
Injectables are not affected by stomach, or intestinal absorption problems.  Larger amount of infusion is available to the tissues. Nutrients are forced into cells by means of a high concentration gradient. Higher doses of nutrients can be given than possible by mouth without intestinal irritation.

I understand that the following will reduce the efficacy of IV / IM nutrition Therapy and that it may take more treatments to reach optimal health:
cigarette smoking; certain medications; caffeine consumption increases Vitamin C excretion; poor diet: processed foods, high sugar intake, nutrient deficient diets; heavy metal toxicity.

I understand that Next Health CANNOT treat me if I currently have cancer OR have had chemo or radiation therapy in the last 6 months

I am aware that other unforeseeable complications could occur. I do not expect the Registered Nurses, Nurse Practitioners, Physicians, and/or other qualified staff members to anticipate and/or explain all risks and possible complications. If any complications do occur, it may require prolonged additional treatments that I will work with the professionals at Next Health to comply with. I will be financially responsible for the treatment of any and all complications.

I understand that IV/IM Nutrition Therapy is not covered by insurance and I understand that if I submit an insurance claim for the IV Nutrition Therapy, that I will be responsible for any and all non-covered services.

I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered in terms and language that I can understand.

I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV/IM therapy with any different or further procedures which, in the opinion of my physician(s) and qualified staff members or other associated with this practice, may be indicated.

I understand that an audio visual monitoring device is used throughout Next Health for safety purposes.

CRYOTHERAPY/ INFRARED / SAUNA THERAPY

Contraindications acknowledgement: Below are Absolute Contraindications and would preclude you from using any of our technology, including the whole-body walk-in cryotherapy chamber, infrared bed or sauna pod, or to be treated with localized cryotherapy equipment. If you have any of the following you may not participate in Cryotherapy Treatment and by signing below you confirm you agree with the following statements:

I HAVE NOT had a heart attack or any heart disease within the previous 6 months

I DO NOT have a pacemaker

I HAVE NOT had heart bypass surgery within the past 6 months

I DO NOT have Congestive Heart Failure

I DO NOT have Chronic Obstructive Pulmonary Disease (COPD)

I DO NOT have Arterial Occlusive Disease

I DO NOT have Raynaud’s Disease

I AM NOT allergic or sensitive to the cold

I DO NOT have an Intrathecal pump (Pain Pump)

I DO NOT have an open wound track or lesions

I DO NOT have a seizure disorder

I AM NOT pregnant

I AM NOT breastfeeding

I AM NOT under the age of 18

I DO NOT have an active infection

I HAVE NOT had chemo or radiation therapy in the last 6 months

I DO NOT currently have cancer

I DO NOT have Trophic Disorders or Tissue Lesions

I AM under the age of 69  

I DO NOT have claustrophobia

I DO NOT have active angina

I DO NOT have a DVT or PE

MY SIGNATURE BELOW CONFIRMS THAT:

I have read and understand the information provided in this form, had all my questions answered, are knowledgeable about the conventional treatments available for my condition, and I am aware that some of the lab testing is not FDA approved and may be considered “unconventional”.

I understand that mild redness may occur for up to 48 hours after a sauna session

Long-term adverse consequences of any recommended therapies may be possible but are unknown at this time.

The provider has adequately explained the procedure set forth to me.

I have received all the information and explanation I desire concerning the procedure.

I authorize and consent to the performance of the procedure as agreed upon.

I have discussed these treatments with my current physician and obtained his/her clearance if I desire.

I, the Patient, is fully accepting all responsibilities for the risks, the Patient, on behalf of himself/herself, his/her heirs, executors, administrators, and assigns hereby fully and completely releases Physician, his successors, and all of his employees, independent contractors, agents, officers, directors, representatives, affiliates and associations (“Released Parties”) from all claims and causes of action by reason of any complication, injury and/or damage which Patient may suffer as a result of any medical services or treatment provided by Released Parties at any time in the past or as a result of any new procedures.

Patient acknowledges and agrees that this release applies to all claims that Patient may have against Physician arising out of the above-described services or any services rendered at any time for injuries, damages, or losses, or for any other services provided in the past by any of the above mentioned “Released Parties”.
Patient warrants and represents that in executing this release, he/she has been given an opportunity to obtain legal advice from an attorney of his/her choice regarding the terms of this release and its consequences and that Patient fully understands the terms of this release.

Patient acknowledges and represents that in executing this release, he/she has not relied on any inducements, promises, or representations made by Physician or any party representing or serving Physician.

Patient acknowledges and warrants that his/her execution of this release is free and voluntary, and he/she fully understands this release.

Patient certifies that he/she has read Section 1542 of the Civil Code, set out below:
A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor.

Patient hereby waives application of Section 1542 of the Civil Code.

Patient understands and acknowledges that the significance and consequence of this waiver of Section 1542 of the Civil Code is that even if Patient should eventually suffer additional damages arising out of the above-described medical services and treatment he/she will not be permitted to make any claim for those damages.
Furthermore, Patient acknowledges that he/she intends these consequences even as to claims for injury and/or damages that may exist as of the date of this release but which Patient does not know exist, and which, if known, would materially affect Patient's decision to execute this release, regardless of whether Patient's lack of knowledge is the result of ignorance, oversight, error, negligence, or any other cause.

In consideration of the fact that these procedures are elective and their effects on children, both unborn and nursing, are untested and unknown, Patient acknowledges that she IS NOT, to the best of her knowledge, pregnant and/or is not breast-feeding and hereby fully releases Physician, his successors, and all of his employees, independent contractors, agents, officers, directors, representatives, affiliates and associations (“Released Parties”) from all claims and causes of action, known or unknown, by reason of any injury and/or damage which Patient and/or her child(ren) has/have suffered or may suffer as a result of any medical services or treatment provided or to be provided by Released Parties.
 
BY SIGNING THIS CONSENT, I UNDERSTAND THESE RISKS/BENEFITS/ALTERNATIVES, AND I AM WILLING TO ACCEPT ALL RISKS.


NOTICE OF PRIVACY PRACTICES

I certify I have read and understand the privacy practices at https://www.next-health.com/pages/hipaa_privacynotices


I ALSO AGREE TO HAVE MY LAB RESULTS, CONSENTS, OR OTHER DOCUMENTS EMAILED TO ME VIA THE EMAIL ADDRESS I HAVE ON FILE WITH NEXT HEALTH

I hereby consent and state my preference to have all NextHealth employees communicate with me by email, social texting apps, or standard SMS messaging regarding various aspects of my medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, and billing. I understand that email and standard SMS messaging are not confidential methods of communication and may be insecure. I further understand that, because of this, there is a risk that email, messaging apps, and standard SMS messaging regarding my medical care might be intercepted and read by a third party.
I have read and accept the terms of the Next Health Consents and Waiver Agreement.
I have read and accept the terms of the Next Health Consents and Waiver Agreement.*
I have to my knowledge honestly answered all Medical Intake questions
I have to my knowledge honestly answered all Medical Intake questions*
Signature*