Billing and Charges Statement

I warrant to Serene Bold Health Clinic that I am not a user of illegal drugs or controlled substances and currently am not under the influence of nor recovering from the use of illicit substances at the time of the provision of services to me.

The provider reserves the right to refuse a prescription (including phentermine) if it is deemed that you have a prescription is not indicated, you have a history of taking the medication beyond the clinically recommended period, and a history of obtaining control substance from different providers upon checking the Prescription Management Program system.

The price paid is for the clinical consultation with the provider ONLY and does not in any shape or form cover the cost of medication prescribed or any other additional services that were ordered (i.e. lab, imaging, referrals). 

No refund will  be issued after a clinical consultation has taken place. 

If medications were dispensed in the clinic, no return will be accepted as required by the law and no refund will be issued.  

By signing below, you acknowledge that you have read the entire statement above, understand the statement, and agree to abide to the statement to its full extent.  

GENERAL CONSENT FOR TREATMENT/SERVICES

I understand the possible complications of injection therapy includes but not limited to: minor bruising and bleeding at injected sites, dizziness, headaches and possible fainting from the site of blood.

I understand clearly that there may be a slight chance for sensitivities and reactions to injection solutions. I hereby release Serene Bold Health Clinic and its staff, members and associates from all liabilities regarding my treatment associated with vitamin and supplement injections.

I acknowledge and agree that the sole risk of injury or harm resulting in any manner from my choosing to participate in such regiment rests entirely with me to the extent that I do not disclose my health conditions, medications, or drug use in advance.

I expressly represent and warrant to Serene Bold Health Clinic 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 regiments made available by Serene Bold Health Clinic nor will screen for, diagnose, monitor, or other provide any care or treatment for such conditions.

I warrant to Serene Bold Health Clinic that I am not a user of illegal drugs or controlled substances and currently am not under the influence of nor recovering from the use of illicit substances at the time of the provision of services to me.

IN THE EVENT OF AN EMERGENCY CALL 911 OR PROCEED TO THE NEAREST EMERGENCY ROOM

I understand that the vitamins and supplements provided by Serene Bold Health Clinic are not intended as supplements for medical treatment. They are considered to be wellness products. Some supplements are contraindicated for pregnant women and therefore one should not take these products if pregnant. The FDA has not recommended any of these supplements as a treatment for a particular disease, although there is literature supporting the use of many of the types of supplement we offer. There is no obligation that I purchase the supplements.

By signing this document, I acknowledge that I have read all the above and understand all features of the above consent.

NOTICE OF PRIVACY PRACTICES

Federal law sets rules for health care providers and health insurance companies about who can look at and receive our health information. This law, called the Health Insurance Portability and Accountability Act of 1996 (HIPAA), gives you rights over your health information, including the right to get a copy of your information, make sure it is correct, and know who has seen it. You can ask to see or get a copy of your medical record and other health information.
If you want a copy, you may have to put your request in writing and pay for the cost of copying and mailing. You can ask to change any wrong information in your file or add information to your file if you think something is missing or incomplete. By law, your health information can be used and shared for specific reasons not directly related to your care, like making sure doctors give good care, reporting when the flu is in your area, or reporting as required by state or federal law. In many of these cases, you can find out who has seen your health information.
You can: Learn how your health information is used and shared by your doctor or health insurer. Generally, your health information cannot be used for purposes not directly related to your care without your permission.
For example, your doctor cannot give it to your employer without your written authorization.
Let your providers or health insurance companies know if there is information you do not want to share.
You can ask for other kinds of restrictions, but they do not always have to agree to do what you ask, particularly if it could affect your care.
Finally, you can also ask your health care provider not to tell your health insurance company about care you receive or drugs you take, if you pay for the care or drugs in full and the provider does not need to get paid by your insurance company.
Acknowledgement of Receipt of Notice of Privacy Practices The Notice of Privacy Practices is a complete description of my rights as a patient of SBHC.