This document is intended to serve as confirmation of informed consent for all types of procedures and services with Next Health Management Group, Inc., its affiliates, subsidiaries and franchisees, their officers, agents, employees, successors, licensees, and assigns (“Next Health”).
Patient must be at least fifteen (15) years old. If a minor, please use the General Intake Form (Minors). If Patient’s age is seventy (70) and over, a Next Health provider Good Faith Exam (“GFE”) is required for all wellness and technology services. The Next Health provider may request an additional Medical Clearance Form, which must be signed by Patient’s Primary Care Provider (“PCP”), clearing Patient for these services.
Patient attests that he/she/they is/are not pregnant, breastfeeding, or under the influence of alcohol or unprescribed drugs, during the time of treatment with Next Health.
By signing below, Patient confirms that he/she/they have/has informed Next Health medical team of Patient’s complete medical history, including any known allergies to drugs or other substances, of any past reactions to anesthetics or medications, and any current medications and supplements being taken.
Patient confirms that he/she/they has/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.
Patient understands that the place performing the lab is a contracted lab company and specimens must be sent to the lab 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 Patient’s personal health information will be disclosed to the lab for identification purposes.
The fee that Patient is 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 Patient requires additional testing or follow-up, Patient will be financially responsible for these.
Patient is responsible to share all results with Patient’s PCP and obtain clearance from Patient’s PCP for any further treatment, procedures, diet changes, or lifestyle change, supplement or medicine change, or any change Patient decides to make whatsoever.
Patient acknowledges that Next Health medical team is not Patient’s primary medical provider. If Patient does not have a PCP, he/she/they will acquire one immediately.
Patient is aware that other unforeseeable complications could occur. Patient does not expect Next Health’s medical team to anticipate and/or explain all risks and possible complications. If any complications do occur, it may require prolonged additional treatments that Patient will work with the professionals at Next Health to comply with. Patient will be financially responsible for the treatment of any and all complications.
Patient understands that all testing done at Next Health is not covered by insurance and Patient understands that if Patient submits an insurance claim for any Next Health treatments or tests,, that Patient will be responsible for any and all non-covered services.
Patient understands the risks and benefits of the procedure and has had the opportunity to have all of his/her/their questions answered in terms and language that Patient can understand.
Patient understands that he/she/they has/have the right to consent to or refuse any proposed treatment at any time prior to its performance. Patient’s signature on this form affirms that Patient has given he/she/they consent to lab testing with any different or further procedures which, in the opinion of Patient’s PCP and Next Health’s medical team may be indicated.
Patient understands that an audio visual monitoring device is used throughout Next Health for safety purposes.
Telehealth involves the delivery of healthcare services through electronic means, allowing for remote interactions between healthcare providers and patients. It may encompass various methods such as electronic transmission of medical records, photo images, personal health information, and audio/video communication. Alternative in-person services may also be available, and it is important to discuss these options with your provider. Patient understands that during telehealth consultations, Patient must be physically located in the state where Patient’s provider is licensed to practice.
Potential Benefits. Utilizing telehealth can offer several potential benefits, including improved accessibility to medical care and services, flexibility in scheduling appointments, and convenient interactions with healthcare providers without the need for in-office visits.
Potential Risks. While telehealth presents potential benefits, it is important to acknowledge the associated risks. These risks include the possibility of limited quality, accuracy, or effectiveness of services provided through telehealth. Technological issues may arise, such as errors, functionality limitations, or data corruption, which could impact the correct diagnosis or treatment by the provider. Additionally, certain tests or in-person assessments may be necessary in some cases, and the unavailability of these assessments through telehealth may lead to the need for alternative healthcare or emergency services. Delays in evaluation or treatment may occur due to provider availability or technological failures. Furthermore, there is a risk of privacy breaches or unintended disclosure of personal health information when using electronic systems for communication.
Data Privacy & Protection. The telehealth system will implement security protocols to protect the privacy and security of patient information. However, it is important to note that the security and privacy of the communication services used, such as email, cannot be guaranteed by the telehealth provider. Personal information containing protected health information (“PHI”) will not be disclosed to third parties without consent, except as authorized by law for consultation, treatment, payment/billing, and certain administrative purposes, as outlined in the provider's Notice of Privacy Practices.
By signing this Next Health General Medical Intake Form, Patient is irrevocably giving permission to Next Health to take and use photographs, video or sound recordings of Patient through Next Health’s telemedicine application and/or while at any Next Health location.
This is completely voluntary and up to Patient. Patient’s consent to the use of the photographs, video and sound recordings and Patient’s image, likeness, appearance, and voice is for forever. Patient will not receive compensation for the use of Patient’s image, likeness, appearance, and voice now or in the future. Next Health may use the photographs, video and sound recordings containing Patient’s image, likeness, appearance and voice in any manner or media, including use on web pages. The photographs, video and sound recordings may be used in whole or in part, alone or with other recordings. The photographs, video and sound recordings may be used for any educational, institutional, scientific or informational purposes whatsoever, but not for any commercial uses. Next Health has the right and may allow others to copy, edit, alter, retouch, revise and otherwise change the photographs, video and sound recordings at Next Health’s discretion. All right, title, and interest in the photographs, video and sound recordings belong solely to Next Health.
Patient further gives permission to Next Health to use Patient’s name, biography, and any other personal data, events, or other material in or in connection with any such uses of the photographs, video and sound recordings. Patient understands and agrees to the conditions outlined in this form. Patient irrevocably gives consent to Next Health forever to make use of Patient’s image, likeness, appearance, and voice in photographs, video and sound recordings as described above. Patient acknowledges that Patient is fully aware of the contents of this form and is under no disability, duress, or undue influence at the time of the execution of this form.
Patient requests and consents to an evaluation by Next Health and its medical team (collectively, “Practice”) of a certain laboratory test(s) run on Patient’s bloodwork. Patient wishes to rely on Practice to exercise its professional judgment only in reviewing the results of Patient’s Bloodwork and making suggestions regarding healthcare services resulting from such results. Patient acknowledges, agrees, and certifies that:
1. Patient understands Practice is not Patient’s PCP.
2. Patient understands that Practice’s only function as it relates to Patient is the review of Patient’s bloodwork and related recommendations.
3. Patient understands Practice’s recommendations are not a treatment order and Patient will not treat them as such.
Patient understands that it is solely Patient’s duty and responsibility to follow up with Patient’s PCP, regarding Patient’s results and recommendations.
Patient understands that as part of Patient’s follow up, Patient will share the results of his/her/their bloodwork and Practice’s recommendations with Patient’s PCP.
Patient understands that Patient’s PCP must review Practice’s results and recommendations, approve or modify the same, and develop a treatment plan for Patient.
Patient understands that he/she/they will not act on the bloodwork results or Practice recommendations without the involvement of Patient’s PCP.
Patient understands that Practice is not treating Patient and any questions Patient may have regarding his/her/their treatment, potential treatments, alternatives to such treatments, potential side-effects, and complications should be directed to Patient’s PCP. Patient further understands that if Patient desires for Practice to treat Patient, Patient must engage Practice separately and apart from this Acknowledgement and Consent and complete the appropriate patient intake paperwork and assessment. Patient also understands that this Acknowledgement and Consent does not establish Patient as a patient of Practice and will not result in treatment by Practice.
Patient understands that the practice of medicine and surgery is not an exact science. Patient further understands and accepts that fees are paid for performance of medical services only, and not a guaranteed result. Patient acknowledges by Patient’s 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.
The procedure involves inserting a needle into a vein or muscle and injecting the prescribed solution intravenously.
Alternatives to intravenous (“IV”) therapy are oral supplementation and/or dietary and lifestyle changes.
Risks of IV / intramuscular (“IM”) 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 IV/IM 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.
Patient understands 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.
Patient understands that Next Health CANNOT treat Patient, if Patient currently has cancer or has had chemo or radiation therapy in the last six (6) months.
Patient understands that if Patient is pregnant, breastfeeding, or has impaired female fertility, Patient should not receive Ketorolac (Toradol). The FDA has classified this medication as a “Category C” medication, which may cause complications during pregnancy, such as premature closure of the feral ductus arteriosus, fetal renal impairment, inhibition of platelet aggregation, and delayed labor and delivery. Epidemiological studies suggest an increased risk of miscarriage after the use of a prostaglandin synthesis inhibitor in early pregnancy.
Patient understands that if Patient is pregnant or planning to become pregnant, Patient should discuss the use of Zofran with Patient’s PCP, due to the possible risk of teratogenicity, including oral cleft and cardiovascular defects. These risks may be especially relevant during the first (1st) trimester of pregnancy. By signing this consent form, Patient acknowledges that Patient has discussed these risks with a healthcare professional and Patient is aware of the potential implications of receiving Zofran.
By signing this consent form, Patient releases Next Health from any liability arising from the administration of Ketorolac (Toradol) and or Zofran. Patient agrees to hold harmless and indemnify Next Health from any claims, losses, or damages resulting from the use of these medications.
Patient is aware that other unforeseeable complications could occur. Patient does not expect the Next Health medical team to anticipate and/or explain all risks and possible complications. If any complications do occur, it may require prolonged additional treatments that Patient will work with the professionals at Next Health to comply with. Patient will be financially responsible for the treatment of any and all complications.
Patient understands that IV/IM Nutrition Therapy is not covered by insurance and Patient understands that if Patient submits an insurance claim for the IV Nutrition Therapy, that Patient will be responsible for any and all non-covered services.
Patient understands the risks and benefits of the procedure and have had the opportunity to have all of Patient’s questions answered in terms and language that Patient can understand.
Patient understands that Patient has the right to consent to or refuse any proposed treatment at any time prior to its performance. Patient’s signature on this form affirms that Patient has given Patient consents to IV/IM therapy with any different or further procedures which, in the opinion of Next Health and Patient’s PCP, may be indicated.
Patient understands that an audio / visual monitoring device is used throughout Next Health for safety purposes.
Contraindications Acknowledgement:
Below are Absolute Contraindications and would preclude Patient from using any of Next Health’s technology, including the whole-body walk-in cryotherapy chamber, infrared bed or sauna pod, or to be treated with localized cryotherapy equipment. If Patient has any of the following, Patient may not participate in Cryotherapy Treatment and by signing below you confirm you agree with the following statements:
PATIENT HAS NOT had a heart attack or any heart disease within the previous six (6) months.
PATIENT DOES NOT have a pacemaker.
PATIENT HAS NOT had heart bypass surgery within the past six (6) months.
PATIENT DOES NOT have Congestive Heart Failure.
PATIENT DOES NOT have Chronic Obstructive Pulmonary Disease (“COPD”).
PATIENT DOES NOT have Arterial Occlusive Disease.
PATIENT DOES NOT have Raynaud’s Disease.
PATIENT DOES NOT have an allergy or sensitivity to the cold.
PATIENT DOES NOT have an Intrathecal pump (Pain Pump).
PATIENT DOES NOT have an open wound track or lesions.
PATIENT DOES NOT have a seizure disorder.
PATIENT IS NOT pregnant.
PATIENT IS NOT breastfeeding.
PATIENT IS NOT under the age of eighteen (18), unless completing certain lab testing procedures for which the minimum age is fifteen (15) years of age with a guardian present.
PATIENT DOES NOT have an active infection.
PATIENT HAS NOT had chemo or radiation therapy in the last six (6) months.
PATIENT DOES NOT currently have cancer.
PATIENT DOES NOT have Trophic Disorders or Tissue Lesions.
PATIENT is under the age of sixty-nine (69), unless completing lab testing procedures for which there is no upper age limit.
PATIENT DOES NOT have claustrophobia.
PATIENT DOES NOT have active angina.
PATIENT DOES NOT have a DVT or PE.
PATIENT’S SIGNATURE BELOW CONFIRMS THAT:
Patient has read and understands the information provided in this form, had all his/her/their questions answered, is knowledgeable about the conventional treatments available for Patient’s condition, and is aware that some of the lab testing is not FDA approved and may be considered “unconventional”.
Patient understands that mild redness may occur for up to forty-eight (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 Patient.
Patient has received all the information and explanation Patient desires concerning the procedure.
Patient authorizes and consents to the performance of the procedure as agreed upon.
Patient has discussed these treatments with Patient’s PCP, and obtained clearance if desired.
Patient is fully accepting all responsibilities for the risks. Patient, on behalf of himself/herself/theirselves, his/her/their heirs, executors, administrators, and assigns hereby fully and completely releases the Next Health medical team, their successors, and all of their 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 the Next Health medical team, 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/they has/have been given an opportunity to obtain legal advice from an attorney of his/her/their 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/they has/have not relied on any inducements, promises, or representations made by the Next Health medical team.
Patient acknowledges and warrants that his/her/their execution of this release is free and voluntary, and he/she/they fully understands this release.
Patient certifies that he/she/they has/have 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/they will not be permitted to make any claim for those damages.
Furthermore, Patient acknowledges that he/she/they intend(s) 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 he/she/they IS/ARE NOT, to the best of his/her/their 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 his/her/their 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, PATIENT UNDERSTANDS THESE RISKS / BENEFITS / ALTERNATIVES, AND PATIENT IS WILLING TO ACCEPT ALL RISKS.
Patient certifies Patient has read and understands the privacy practices at https://www.next-health.com/pages/hipaa_privacynotices, as well as any applicable polices below:
Lab Manufacturers’ Terms & Privacy Policies. For each lab, please see its link below to view its Terms & Conditions and/or Privacy Policies.
Vibrant Wellness
Terms of Use
Privacy Policy
Testing Policy
Disclaimer
Quest Diagnostics
Privacy Page
Terms & Conditions
DUTCH Test
3x4 Genetic Test
Terms of Service
Cookie Policy
Grail- Galleri Cancer Detection Test
Privacy Notices
HIPAA Notice
Invitae- Genetic Risk Panel
TruDiagnosticsTruAge Test
FCOI Policy
Vitract- Gut Microbiome Test
PATIENT ALSO AGREES TO HAVE PATIENT’S LAB RESULTS, CONSENTS, OR OTHER DOCUMENTS EMAILED TO PATIENT, VIA THE EMAIL ADDRESS PATIENT HAS ON FILE WITH NEXT HEALTH.
Patient hereby consents and states his/her/their preference to have all NextHealth employees communicate with Patient by email, social texting apps, or standard SMS messaging regarding various aspects of Patient’s medical care, which may include, but shall not be limited to, test results, prescriptions, appointments, and billing. Patient understands that email and standard SMS messaging are not confidential methods of communication and may be insecure. Patient further understands 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 (3rd) party.
Patient has read and accepted the terms of Consent & Waiver section of this General Medical Intake Form.
Patient has, to the best of Patient’s knowledge, honestly and accurately answered all medical Intake questions included in this form.
