I give consent to care rendered by Concierge APRN, including the medical director, nurse practitioner, nurse, or any other staff person. Care may include, but is not limited to: Obtaining a medical history, Obtaining vital signs, performing a physical exam or telemedicine exam, and providing treatment as deemed necessary. I understand that the practice of medicine is not an exact science and that diagnosis and treatment may involve risk of injury or even death.

I hereby acknowledge that I am aware of all potential risks associated with infusion treatment including, but not limited to, pain, bleeding, swelling at the infusion site, infection, lightheadedness, allergic reaction, bruising and/or even fainting. Concierge APRN will not be held accountable for any possible treatment reaction.

I acknowledge that no guarantees have been made to me regarding the result of examination or treatment by Concierge APRN. As with any medical treatment some patients may not respond to therapy. I understand that Concierge APRN may create a customized therapy to meet my needs which may not be reviewed or approved by the FDA or any other entity for safety, quality, or effectiveness.

I knowingly and voluntarily consent to such therapies. I have made the medical provider and medical staff aware of all my known health conditions, allergies and medications I am taking, including herbal medications/supplements.

I consent to receiving a medical screening or delivery of healthcare services by Concierge APRN via telehealth/telemedicine methods, and understand that there are certain risks associated with receiving care through these methods. I understand that Concierge APRN will consult with me about the risks and benefits associated with receiving care through a telemedicine interaction upon my request. I understand that I have the option to withdraw such consent and request an in-person screening without an effect on the access to care I receive from Concierge APRN.

I understand that the terms herein are contractual and not a mere recital; and that I sign this document as my own free act and void of any coercion. The permissions granted herein shall begin on the date listed below and shall remain effective until terminated by the undersigned.

I understand that by signing this form I authorize Concierge APRN to release confidential health information about me, by releasing a copy of my medical record, or a summary or narrative of my protected health information collected to my employer, contracting company, and Concierge APRN’s Providers and staff. I hereby give Concierge APRN permission to utilize any digital images for social media and advertising purposes.

My signature below verifies that I have read all of the information contained in this Medical Consent Form and that I have asked questions about anything I have not understood up to this point. My signature will also release and hold harmless Concierge APRN and their providers, staff, and all employees from any and all liabilities, or claims whether known or unknown arising out of, in connection with, or in any way from the care provided.