Informed Consent for Treatment
Thank you for choosing IVitality, we appreciate you trusting in us as your partner in decision-making regarding your care. I encourage you to ask questions and collaborate with me to determine a treatment plan that works best for you. This document outlines our education, background, privacy practices, and general policies for IVitality.
WELCOME
Here at IVitality our approach combines the expertise of health professionals with cutting-edge technology to deliver tailored health services for men and women. Our doctors are board-certified Naturopathic Doctors. All IV therapy is administered by our Registered Nurses who specialize in IV therapy.
By completing this waiver and utilizing services at IVitality LLC, users acknowledge that therapies provided, including but not limited to Red Light Therapy, Compression Therapy, Infrared Sauna, Percussive Therapy, Ozone Therapy, IV Therapy, Nutrient Shots, Cryotherapy, and Bioidentical Hormone Replacement Therapy, are considered investigational/experimental. Users accept and voluntarily assume all risks related to injuries, damages, or harm that may occur during or as a consequence of participating in any treatment.
OFFICE HOURS
IVitality Bellingham:
Monday-Friday 10am-7pm, closed for lunch from 2pm-3pm.
IVitality Issaquah:
Open 7 days a week 10am-7pm, closed for lunch from 2pm-3pm
IVitality Bellevue:
Open 7 days a week 10am-7pm, closed for lunch from 2pm-3pm
Chart/Electronic health record:
Your clinical chart will contain electronic information and may contain paper documents. Any paper documents will be scanned into your electronic chart and destroyed. You have the right to view the documents in your file unless it is determined that it would be clinically inappropriate to do so. Your electronic records will be maintained for seven years after conclusion of services.
CONFIDENTIALITY
Information shared in treatment is confidential and is not discussed with anyone without a signed release form. There are legal limits to confidentiality including:
Judge ordered testimony in proceedings involving child custody or where emotional condition is an important issue,
Concerns about child abuse/elder abuse,
Concerns the client is a threat to do serious bodily harm to self or others, or if a client is considered gravely disabled,
If any of the above concerns exist during treatment, all providers are legally mandated to report to the appropriate authorities.
We do not accept Insurance
A C K N O W L E D G E M E N T O F
N O N – I N S U R A N C E C O V E R A G E
I agree, and it has been explained to me, that the following services performed at IVitality, Cedar
Male Medical, and Maidenhair Hormone Clinic are not generally considered and accepted, with respect to insurance coverage.
-IV Therapy
-Nutrient Shots
-Supplements (botanicals, homeopathic,
nutraceuticals, etc.)
-Other supplies (Kinesio Tape, etc.)
-Cryotherapy
-Compression Therapy
-Infrared Sauna
-Ozone Therapy
-Red Light Therapy
-Percussive Therapy
(Hypervolt, Theragun, etc.)
-Bioidentical Hormone Replacement Therapy
(BHRT)
Usual and customary Evaluation and Management, or other medically necessary services, may be billable to my insurance, but IV/injection services and supplies, supplements, and other supplies/services cannot be billed. I understand that this requires my payment in full for all IV/injection services and supplies, supplements, and other supplies/services. I additionally understand that I may not attempt to bill
my own insurance company for any of these services. Insurance deems these therapies
investigational/experimental.
Fees for Medication Management and Therapy Services:
ALL SALES ARE FINAL.
We do not offer returns of medications or unused services, or subscription purchases.
MONTHLY MEMBERSHIP SUBSCRIPTIONS
All patients receiving treatment with IVitality must have a card on file for Monthly, Quarterly or Annual auto charging due to your monthly subscription including ordering medications that are patient specific, Our team and providers time, and lab work. You can cancel treatment at anytime by sending an email to Cancel@IVitalitylife.com. (Must send cancelation email at least 24hours before Auto charging date)
NO SHOW/LATE CANCEL FEE for IV Therapy: If an appointment is canceled within 3 hours or No show to appointment. The patient is charged for the full price of the IV treatment.
CARD ON FILE
All patients must have card on file to schedule IV therapy at IVitality.
Forms of payment accepted: Debit, Credit, Check, and HSA/FSA.
Monthly Subscriptions
MONTHLY SUBSCRIPTIONS
All monthly subscriptions not only include your medications but also your lab work and time with our providers. We do not offer refunds or credits if appointments are missed or lab work is not completed. We provide Lab work to our patients every 3 months when on treatment with us, however it is the patients responsibility to complete the labs prescribed by our doctors.
MEDICATION
All medication will be shipped directly to the patient and the patient is responsible to make sure to keep our office informed on the correct address for shipment. We are not responsible to replace medications if they are shipped to a previous address or an address not intended by the patient.
CARD ON FILE
All monthly subscriptions require a card on file for treatment. Patients are responsible for keeping the card on file up to date and will not receive shipments of medications, lab work or appointments with our providers if account balances are due.
TO CANCEL SUBSCRIPTION
Patients can cancel subscriptions at anytime by sending an email to Cancel@IVItalitylife.com. Please provide your cancelation email 24 hours before your auto charging date for us to process your cancelation.
Appointment Cancellation
Please give at least 24-hour notice if you need to cancel or reschedule your appointment. If you no-show or cancel with less than 24-hour notice, this will count as a No Show OR Late Cancel and fees may apply. See above.
Medications:
There are no guarantees to the outcomes of medications. You will be involved in the choice of your prescribed medications and be provided with rationale regarding treatment approaches. You have the right to refuse recommended medications, seek a second opinion, or terminate treatment at any time. We will discuss the possible consequences of stopping medications abruptly. All medications may produce undesired effects, and some can cause undesired outcomes. We will discuss the most common undesired effects with you.
Please request medication refills no less than 7 business days before the medication is needed. Otherwise, we cannot guarantee your medication will be filled before you run out.
Controlled substances will not be refilled sooner than your monthly subscription charging date.
10. Telehealth Services:
I understand that I am consenting to remote services via video and this treatment is voluntary.
All applicable confidentiality protections shall apply to the services.
I understand that I will need access to a smartphone, tablet, or computer with internet access, and that utilizing a secure internet connection rather than public/free Wi-Fi is recommended.
I understand that, in order to maintain confidentiality, I should strive to attend appointment in a confidential space.
I understand that given the nature of telehealth, there is a possibility of technological glitches.
I understand that driving during sessions is prohibited by IVitality LLC.
EMERGENCY AND URGENT SERVICES
IN THE EVENT OF A MEDICAL EMERGENCY CALL 911.
In the event of an emergency or urgent need, please reach out to emergency services first and only contact our offices AFTER you have received the appropriate care.
While we understand that you have trust in us, the following are the appropriate resources for such an event, and we want you to be the safest that you can possible be:
In an emergency please go to the Emergency Department or call 911
Crisis Text Line available 24/7. Text MN to 741741 The National Suicide Prevention Lifeline at 988 (call/text)
POISON CONTROL CENTER 1-800-222-1222 OR 911 OR go to nearest ER
You can reach our Emergency Line by calling us at (425)-440-3080 option #5.
I voluntarily consent for service provided by IVitality. Services may include: diagnosis and evaluation, therapeutic methods, and medication management and any other care provided by the IVitality care team. I have been offered/received a copy of the policies of IVitality LLC.I have read and understand these policies and agree to abide by them.
