Terms & Conditions
YOU SHOULD CAREFULLY READ ALL THE FOLLOWING TERM AND CONDITIONS!
By signing below, you are agreeing to the following Terms and Conditions of our engagement. You must return a signed copy of this document to IVBUTLER MEDICAL P.C. prior to receiving services. The services recipient is referred to herein as “client”, “I” or “you”. These terms to which you agree are referred to as “Terms and Conditions” or “Agreement”. Client understands that participating with IVBUTLER MEDICAL
P.C. which offers intravenous (IV) hydration, intramuscular (IM) injections, subcutaneous injections, vitamin/supplement administration, and medication administration services and programs, carries risks. Risks include, but are in no way limited, to the following: Injury, bleeding, infection/phlebitis, inflammation/swelling, bruising or scarring resulting from IV infiltration, extraction and/or extravasation, misplacement of IV lines in the body, air embolism, fluid overload, adverse medication reactions and/or interactions, nerve injuries, lightheadedness, headache or
fainting, pain or burning during insertion of IV catheter. I acknowledge and agree that any risk of injury, harm or complication resulting in any manner from my choosing to participate in such services or regiments, rests entirely on me (the patient), to the extent that I fail to disclose any of my health conditions, medications or drug use in advance. I also acknowledge and agree that I have not submitted any false
information to IVBUTLER MEDICAL P.C., that can harm or injure me during any of their services.
I expressly represent and warrant to IVBUTLER MEDICAL P.C. that I have never been diagnosed with nor treated for any diseases, illnesses or conditions which may result in increased risk when I participate in regimens, programs or services made available by IVBUTLER MEDICAL P.C., and I am not choosing to participate with any expectation that IVBUTLER MEDICAL P.C. will screen for, diagnose, monitor or otherwise provide any care or treatment for such conditions.(This information is to be submitted in the Past medical/surgical history section before any services are performed).
I acknowledge and understand that IVBUTLER MEDICAL P.C. is relying upon the foregoing representations and warranties that I am providing to IVBUTLER MEDICAL P.C. in choosing to accept me for participation in its programs and services.
I acknowledge that IVBUTLER MEDICAL P.C. has made no warranties or guarantees as to the results or general success of any intravenous (IV) hydration, intramuscular (IM) injections, subcutaneous injections, vitamin and supplement administration, medication administration services/programs or any other services made available by IVBUTLER MEDICAL P.C. All information given and expressions made by IVBUTLER MEDICAL P.C. relative thereto, are opinions that should not be relied upon. I acknowledge that additional damages may occur to my property made available by IVBUTLER MEDICAL P.C. including, but not limited to, damages caused by blood staining my property. I hereby hold IVBUTLER MEDICAL P.C. entirely harmless, innocent and fully indemnify IVBUTLER MEDICAL P.C. against all such damages.
I acknowledge that the services provided have not been evaluated by the FDA. I acknowledge that these products are not
intended to diagnose, treat or cure any disease. I expressly represent and warrant to IVBUTLER MEDICAL P.C. that I am not a user of illegal drugs and/or controlled substances and I am not under the influence of same or recovering from use of same at the
time of the provision of services to me. In the event of an emergency, I will be sure to call 911 or proceed to the nearest emergency room.
Acknowledgement: I confirm that I have read this form and fully understand its contents. I acknowledge that no guarantees or assurances have been made to me concerning the results intended from the services, sessions and/or programs offered by IVBUTLER MEDICAL P.C. I understand the nature of the services, sessions and programs and that participating in them carries risks. I have been given contact information to ask any questions, and opportunity to ask any questions and all of my questions have been answered fully and to my satisfaction. I
agree to my assumption of all risks associated with my participation.
Patient Authorization for Use and Disclosure of Protected
I authorize IVBUTLER MEDICAL P.C. to use and/or disclose certain protected health information (PHI) about me if needed.
This authorization permits IVBUTLER MEDICAL P.C. to use and/ or disclose the following individually identifiable health information about me include, but are not limited to: Date(s) of services, type of services, origin of information, age, gender and vital signs. The information will be used or disclosed for the following purpose:
Obtaining research data to reflect growth, sales, and/or types of services requested by our client population. The purpose is
provided so that I can make an informed decision whether to allow release of the information. This authorization will expire one (1) year from date of service. The practice will not receive payment or other remuneration from a third party in exchange for using or disclosing the PHI.
l do not have to sign this authorization in order to receive treatment from IVBUTLER MEDICAL P.C. In fact, I have the right to refuse to sign this authorization. When my information is used or disclosed pursuant to this authorization, it may be subject to redisclosure by the recipient and may no longer be protected by the federal HIPAA Privacy Rule. I have the right to revoke this authorization in writing except to the extent that the practice has acted in reliance upon this authorization. I authorize and acknowledge all of the aforementioned charges and any additional charges will be posted to my credit card in the form of an advance deposit or for full payment for the person(s)/service(s) designated above. I acknowledge that any additional fees incurred for additional services that were not previously ordered nor included above, may also be charged to my credit card. I understand that upon receipt of this form, IVBUTLER MEDICAL P.C. may hold sufficient funds to cover the anticipated charges. I understand the final charges may be different than the initial charge due to additional charges or a change in service(s), and I will get an invoice of the final bill after the service(s) is completed. All services will be provided and billed by IVBUTLER MEDICAL P.C. unless stated otherwise.
I agree to the following cancellation Policy. Cancellations with less than an 8 hour notice of the reserved appointment price will be charged 100% of the appointment price to the held credit card on file, in accordance to the cancellation policy. A credit to reschedule the appointment will be allowed for the next 24 hours of the time cancelled with no rebooking fee. If a medical provider has already been dispatched to the clients location, or if you are not present at the given address within 20 minutes of the medical provider’s arrival, this will be considered a no-show and you will be charged 100% of the non refundable fee. In the unusual event, we are unable to provide our services to you because of our availability, a CREDIT or a REFUND WILL BE PROVIDED. Credits or refunds will not be provided to customers who are unsatisfied with the services.
In the event that the medical professional engaged by IVBUTLER MEDICAL P.C. is unable to perform the portion of the scheduled service(s) that follows the insertion of the I.V. needle due to circumstances out of the medical professional’s control (e.g. the I.V. drip will not begin after the medical professional has made an attempt), you will receive a credit or refund of the full amount of the services scheduled, less a medical assessment fee of one hundred dollars ($100.00). IVBUTLER MEDICAL P.C.Insurance not accepted, clients responsibility for payment.
Client understands and acknowledges that IVBUTLER MEDICAL P.C. and its personnel are not reimbursed or payed for their services or programs by Medicare, Medicaid, Care Plans or other third party payor programs including clients health insurance carrier. IVBUTLER MEDICAL P.C. does not accept insurance for any services. Clients will be billed directly and will be held responsible for payment, regardless of whether client is or will be reimbursed for services by their Care Plan, Health insurance or other third party programs including clients health insurance carrier.