CONSENTS, TERMS & CONDITIONS
Consent to Treat
I certify that I allow Zobia Health & Aesthetics, LLC and/or Alessandra Zapata, APRN and any of the associates to give me medical treatment for general medical conditions, acute medical conditions, weight management among other treatments. I give consent to medical treatment and medical procedures. All of these procedures that are offered are completely elective and you as my client, always have the opportunity of refusing treatments. We are not your PCP, primary care physician, we encourage you to seek recommendations from your primary care provider for any medically necessary interventions.
In our ongoing efforts to provide you with the best possible service, we ask that you carefully review this consent form and ask any questions necessary to help you fully understand it. Please sign at the bottom only after careful review and consideration.
Disclosure of Medical History - I agree that I will disclose a full and accurate personal medical history, including any and all information regarding medical conditions and my use of medications, drugs, herbs, vitamins or other supplements of any kind. I understand that failure to do so may affect my treatment outcome and increase the likelihood or severity of complications.
Confidentiality - I understand that no information regarding services performed shall be released without my express consent except as follows: I authorize that copies of my records may be sent to another location if I seek additional treatment at that location. I understand that, in addition to authorized clinic personnel, the clinic’s medical director and consulting physicians shall have full access to my treatment records. I understand that appropriate medical review may be conducted to further the safety and efficacy of my practitioner’s services. I understand my practitioner may also provide limited patient information to various third-party vendors to provide database development and maintenance services, referral services or marketing research services. I understand that photographs may be taken to document treatment results, but they will not be released or used otherwise without my specific written consent. My practitioner will maintain file copies of all records for a minimum of three years.
Skin Care Products - I understand that some of the skin care products offered by my practitioner are professional strength and formulated to aggressively treat problem skin. I agree that I will use any skin care products obtained from the clinic in accordance with the instructions and directions provided to me by the clinic staff and only after becoming acquainted with the product and its recommended use. I realize that I may experience varying degrees of discomfort, redness, burning, peeling, itching, dryness or other symptoms, especially in the early stages of use. These symptoms should lessen and eventually subside as my skin tolerance develops. I understand that in unusual circumstances, use of these professional strength products could be harmful and even cause injury to the skin (infection, discoloration, superficial scarring, etc.). I will discontinue use and notify my practitioner if any unusual or concerning irritation occurs. I will not use any of these professional strength products if I am nursing, pregnant or trying to become pregnant. I understand that long-term use is necessary to achieve and retain the desired benefits.
Continued Consent - I understand that my practitioner’s services generally consist of a series of treatment to achieve maximum benefit, and this consent shall apply to all services rendered to me by my practitioner, including ongoing or intermittent treatments.
Our leading expert provider, Alessandra, is a master prepared, board-certified Nurse Practitioner with over 15 years of inpatient and outpatient healthcare experience in a plethora of areas. She has experience with Physical Medicine and Rehabilitation, Pain Management, Internal Medicine, Case Management, Psychedelic Medicine, Obesity Medicine, Aesthetic Medicine & so much more.
Payment, Deposit & Cancellation Policy
Payment Policy - I understand that Zobia Health & Aesthetics does NOT accept commercial insurance or Medicare. I understand that Zobia Health & Aesthetics is a CASH ONLY practice and payment is due at the time that services are rendered.
Deposit Policy - We are always as accommodating as possible to assist our clients, however, due to the high volume and popularity of the treatments we offer, we have felt the need to introduce a formal Deposit and Cancellation Policy. We respect that your time is valuable and we appreciate that you understand ours is too. If appointments are cancelled or rescheduled at short notice, or if you do not attend an appointment, this means we are unable to re-use that time for other clients. A deposit will now be taken when booking any treatment. This will be deducted from your bill for the relevant treatment. Deposits for consultations will be refunded if no treatment is required or able due to medical grounds.
Cancellation Policy- We understand that occasionally a short-notice cancellation may be unavoidable and if it is possible to reschedule your appointment, without causing an issue for our clinic operations, we will try to do so. However, because it is often difficult to re-book an appointment slot within 24 hours, we have taken the decision to institute a 24-hour cancellation policy.
How to Cancel an Appointment: - Call us at 954-408-2250 - Text us at 954-408-2250 - Email us at firstname.lastname@example.org.
Consent to Intravenous Medication & Vitamin Administration
Intravenous or intramuscular fluid administration of saline, vitamins and other cocktails are not FDA approved and are being used off label for a number of reasons. This is a completely voluntary medical procedure and even though recommended by your provider, you can refuse this treatment at any time.
The risks for IV infusion & injections are: - infection - bruising - infiltration - deep vein thrombosis - burning/stinging sensation - allergy & anaphylaxis - hematoma - bleeding - vasovagal reactions such as fainting.
There are many benefits to IV Infusion & injections. The following are some of the indications for receiving an infusion: - fatigue - hangover - dehydration - nausea/vomiting - vitamin deficiency - skin, nail & body balance.
IV Infusions are a completely elective procedure with minimal negative side effects. By signing this consent you are allowing for Zobia Health & Aesthetics, LLC to make IV Infusion & injection recommendations & complete the infusion to get to your very best state of health.
Article 1: Agreement to Arbitrate: It is understood that any and all disputes, including any claims alleging medical malpractice or that any medical services rendered under this contract were unauthorized or improperly, negligently or incompetently rendered, will be determined by submission to arbitration and not by a lawsuit or resort to court process, except as law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of binding arbitration.
Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement shall cover all existing or subsequent claims or controversies whether in tort, contract or otherwise, and shall bind all parties whose claims may rise out of or in any way relate to treatment or services provided by Zobia Health to a patient.
Article 3: Procedure For Initiating Arbitration: Either party to this agreement may initiate arbitration by submitting a Demand for Arbitration in writing by US mail to the other. The demand shall contain a simple statement of the nature of the dispute, amount of damages sought, name and contact information of the patient and the remedy demanded. The arbitrator shall be selected by agreement of the parties on or before 30 calendar days of the postmark date that the demand for arbitration was mailed. There shall be a group of three arbitrators, and they shall be chosen pursuant to FMCS procedure. The arbitrator’s award shall be binding on the parties to the arbitration and judgment on the award may be entered by a court of competent jurisdiction in the state of record. Unless the arbitrators shall determine otherwise, the arbitration shall take place in the county where the services were rendered.
Article 4: Severability: In the event that any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provisions.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO JURY OR COURT TRIAL.
HIPAA Compliance Notice and Consent
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability and Accountability Act of 1966 (“HIPAA”) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
This Notice of Privacy Practices describes how we may use and disclose your protected health/personal information (PHI) to carryout out treatment, payment or business operations (TPO) and for other purposes that are permitted or required by law. It also describes our rights to access and control your protected information. Protected health/personal information is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.
Uses and Disclosures of Protected Health/Personal Information Uses and Disclosures of Protected Health/Personal Information Your protected health/personal information may be used and disclosed by our medical director, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you to support business operations of this office, if requested by you to a finance company to pay for your care, and any other use required by law.
Treatment: We will use and disclose your protected health/personal information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose your protected health/personal information, as necessary, if, as a result of our services, you require treatment by a physician. Your protected health/personal information may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.
Payment: Your protected health/personal information will be used, if requested, to obtain payment for your services. For example, if you desire to finance the costs of your treatments, this may involve disclosing relevant protected private information in order to obtain approval.
Healthcare Operations: We may use or disclose, as needed, your protected health/personal information in order to support the business activities of this office. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, and conducting or arranging for other business activities. In addition, we may use a sign-in sheet at the registration desk where you will be asked to sign your name. We may also call you by name in the waiting room when we are ready to see you. We may use or disclose your protected health/personal information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health/personal information in the following situations without your authorization. These situations include: as required by law; public health issues as required by law, communicable diseases; health oversight; abuse or neglect; Food and Drug Administration requirements; legal proceedings; law enforcement; coroners, funeral directors and organ donation; research; criminal activity and national security; workers compensation; inmates; required uses and disclosures. Under the law, we must make disclosure to you and, when required by the Secretary of the Department of Health and Human Services, to investigate or determine our compliance with the requirements of Section 164.500.
Other Permitted and Required Uses and Disclosures will be made only with your consent, authorization or opportunity to object unless required by law.
You may revoke this authorization, at any time, in writing, except to the extent that this office has taken an action in reliance on the use or disclosure indicated in the authorization.
Your Rights Following is a statement of your rights with respect to your protected health/personal information.
You have the right to inspect and copy your protected health/personal information. Under federal law, however, you may not inspect or copy the following records: information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health/personal information that is subject to law that prohibits access to protected health/personal information.
You have the right to require a restriction of your protected health/personal information. This means you may ask us not to use or disclose any part of your protected health/personal information for the purposes of treatment or healthcare operations. You may also request that any part of your protected health/personal information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.
We are not required to agree to a restriction that you may request. If our medical director believes it is in your best interest to permit use and disclosure of your protected health/personal information, your protected health/personal information will not be restricted. You then have the right to use another service provider.
You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us, upon request, even if you have agreed to accept this notice alternatively, i.e., electronically.
You may have the right to amend your protected health/personal information. If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to our statement and will provide you with a copy of any such rebuttal.
You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health/personal information.
We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.
You may complain to us or to the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.
This notice was published and becomes effective on/or before May 1, 2022.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health/personal information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our Main Phone Number 954-408-2250.
Laboratory Orders & Medication Issues
Laboratory orders can be fulfilled using your current healthcare insurance. Zobia Health is NOT guaranteeing labs will be covered by your insurance. You are responsible to pay for any part of the bill not covered by your insurance.
If you are requiring a refill due to a broken or lost product, the charge will be the cost of the medication. Example, if you lost or broke a vial that costs $225, you will be responsible to pay $225.
We do not guarantee outcomes on any of our medications.
Since medications are specifically tailored and made for you and no one else, we operate with a strict NO REFUND rule, NO EXCEPTIONS.