NOTICE
This page is intended to serve as confirmation of informed consent for any type of procedure and/or services at NEXT|HEALTH.

By selecting "I Agree to terms" on any of our digital communications, you agree that you have informed the qualified staff members of any known allergies to drugs or other substances, of any past reactions to anesthetics or medications, all current medications and supplements that I am taking, and all of my medical history.  

Must be 18+ years of age. If you are over the age of 65, a Medical Clearance Form must be signed by your Primary Care Provider, clearing you for these services. Cannot be pregnant, breastfeeding, or under the influence.

You also agree that you understand that you have been informed of the procedure of taking the blood/urine/genetic specimen, and any feasible alternative options, and the risks and benefits.

REVIEW CONSENTS BELOW.

NEXT|HEALTH COVID-19 SCREENING & CONSENT
This page is intended to serve as confirmation of informed consent for COVID-19 Immune Globulin, PCR, and Rapid Antigen Testing services at NEXT|HEALTH.

I understand that NextHealth is providing a non-FDA approved blood test for COVID Antibodies, PCR nasal swab for molecular specific and antigen testing for rapid results which function under an FDA recognized EUA ( Emergency Use Authorization) for increased testing capability which are both recognized under high complex laboratory conditions and CLIA waived certifications.

I understand that the PCR nasal swab is an FDA approved test for the detection of COVID-19.

I understand that the lab cost includes a processing fee for all COVID testing to help cover the “cost” to NextHealth which includes staff time for the blood draw and shipping/handling of the specimen, as well as interpretation and result reporting along with increased sanitation and personal protective equipment supplied to all staff. This fee does not include any subsequent medical care. NextHealth is not responsible for any medical care beyond providing you with the results of the test. If I have symptoms or require additional care, testing or follow up, I will seek out the guidance of my primary care provider, and I understand I am financially responsible for this. There are NO refunds or complimentary repeat tests offered. All tests must be paid for in full at the price quoted before each test is performed. I understand that all testing done at Next|Health is not covered by insurance and I understand that if I submit an insurance claim for it, that I will be responsible for any and all non covered services.

By signing below, I agree that I have accurately informed the NextHealth staff members of my medical history, any known allergies to medications, all current medications and supplements that I am taking, and any other relevant information to my care.   I am also responsible to share my results with my PCP and obtain advice from my PCP for any further treatment, procedures, diet changes, or lifestyle change, supplement or medicine change, or any change I decide to make whatsoever. I acknowledge that Next|Health, Registered Nurses, Nurse Practitioners, and Physicians are not my primary medical provider. If I do not have a primary care provider, I will seek one out immediately.

I agree that I understand that I have been informed of the procedure of taking the
blood specimen, and any feasible alternative options, and the risks and benefits as detailed as follows:
The procedure of a blood draw involves inserting a needle into a vein and drawing blood to send to a lab. This procedure may produce a local bruise, phlebitis, infection, or other local complication along with nasal irritation and or discomfort to obtain the needed specimen for the other testing methodology.  

During this process, there is a chance for delays, lost specimens, or incorrect results that are not the responsibility of Next|Health.   I also understand that my personal results may be subject to reporting requirements of the study protocol, the CDC, or federal, state or local regulatory bodies.   I understand that my blood or other specimen will be sent off site to the respected laboratories testing facility, and my personal health information will be disclosed to the lab for identification purposes and if needed to the local health department and CDC for tracking.

I am aware that other unforeseeable complications could occur. I do not expect the Registered Nurses, Nurse Practitioners, Physicians, and/or other staff members to anticipate and/or explain all risks and possible complications.

I understand the risks and benefits and alternatives of the procedure and have had the opportunity to have all of my questions answered in terms and language that I can understand. I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my informed consent.
I understand that a visual monitoring device is used throughout NEXT|HEALTH for safety purposes.

BLOOD/SPUTUM/URINE TESTS

• The procedure of a blood draw involves inserting a needle into a vein and drawing blood to send to a lab. This procedure may produce a bruise, phlebitis, or other local complication.
• Other lab testing procedures may be required, such as cheek swab for DNA, urine tests, stool tests, finger stick, breath test, etc.
• I understand that the place performing the lab is a contracted lab company and specimens must be sent to them for analysis. During this process there is a chance for delays, lost specimens, or incorrect results that are not the responsibility of NextHealth.
• The blood or other specimen will be sent off site, and my personal health information will be disclosed to the lab for identification purposes.
• The fee that I am paying for the testing is the cost of the actual test (which may be a small portion of the total fee), the administration and coordination of handling the sample, the venipuncture or collection by an appropriate medical professional, test interpretation by a medical professional, and possibly additional follow up.
• The follow up period for any lab test done is limited to 30 days (or less), and the information provided is limited to the scope of the lab testing done. After this period, I must seek follow up from a primary care provider.
• I am responsible to share all results with my PCP and obtain clearance from my PCP for any further treatment, procedures, diet changes, or lifestyle change, supplement or medicine change, or any change I decide to make whatsoever.
• I acknowledge that NextHealth and it’s employees are not my primary medical provider.
• If I do not have a primary care provider, I will seek one out immediately.
• I am aware that other unforeseeable complications could occur. I do not expect the physician(s) and or other qualified staff members to anticipate and or explain all risk and possible complications.
• I understand that all testing done at NextHealth is not covered by insurance and I understand that if I submit an insurance claim for it, that I will be responsible for any and all non-covered services
• I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.
• I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to lab testing with any different or further procedures which, in the opinion of my physician(s) and qualified staff members or other associated with this practice, may be indicated.
• I understand that a visual monitoring device is used throughout Next Health for safety purposes.

IV DRIPS & VITAMIN TREATMENTS
The procedure involves inserting a needle into a vein or muscle and injecting the prescribed solution intravenously. Alternatives to intravenous therapy are oral supplementation and / or dietary and lifestyle changes.

Risks of intravenous therapy include but not limited to:

1. Occasionally to commonly - discomfort, bruising, pain at the site of injection.
2. Rarely - inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
3. Extremely Rarely - Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.

Benefits of intravenous therapy include:

1. Injectables are not affected by stomach, or intestinal absorption problems.
2. Larger amount of infusion is available to the tissues.
3. Nutrients are forced into cells by means of a high concentration gradient.
4. Higher doses of nutrients can be given than possible by mouth without intestinal irritation.
   
   

• I understand that the following will reduce the efficacy of IV / IM nutrition Therapy and that it may take more treatments to reach optimal health: cigarette smoking; certain medications; caffeine consumption increases Vitamin C excretion; poor diet: processed foods, high sugar intake, nutrient deficient diets; heavy metal toxicity.
• I am aware that other unforeseeable complications could occur. I do not expect the physician(s) and or other qualified staff members to anticipate and or explain all risk and possible complications.
• I understand that IV/IM Nutrition Therapy is not covered by insurance and I understand that if I submit an insurance claim for the IV Nutrition Therapy, that I will be responsible for any and all non-covered services.
• I understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered.
• I understand that I have the right to consent to or refuse any proposed treatment at any time prior to its performance. My signature on this form affirms that I have given my consent to IV/IM therapy with any different or further procedures which, in the opinion of my physician(s) and qualified staff members or other associated with this practice, may be indicated.
• I understand that a visual monitoring device is used throughout Next Health for safety purposes.
• I understand that I cannot be pregnant, breastfeeding, or under the influence for these services.

CRYOTHERAPY/INFRARED LIGHT OR SAUNA THERAPY

Contraindications acknowledgement: Below are Absolute Contraindications and would preclude you from using any of our technology, including the whole body walk-in chamber, infrared or sauna, or be treated with localized cryotherapy equipment. If you have any of the following you may not participate in Cryotherapy Treatment and by selecting "I Agree to terms" on any of our digital communications you confirm you agree with the following statements:

• I HAVE NOT had a heart attack or any heart disease within the previous 6 months
• I DO NOT have a pacemaker
• I HAVE NOT had heart bypass surgery within the past 6 months
• I DO NOT have Congestive Heart Failure
• I DO NOT have Chronic Obstructive Pulmonary Disease (COPD)
• I DO NOT have Arterial Occlusive Disease
• I DO NOT have Raynaud’s Disease
• I AM NOT allergic or sensitive to the cold
• I DO NOT have an Intrathecal pump (Pain Pump)
• I DO NOT have an open wound track or lesions
• I DO NOT have a seizure disorder
• I AM NOT pregnant
• I AM NOT under the age of 18
• I DO NOT have an active infection
• I have NOT had chemo or radiation therapy in the last 6 months
• I DO NOT have Trophic Disorders or Tissue Lesions
• I AM under the age of 65
• I DO NOT have claustrophobia
• I DO NOT have active angina
• I DO NOT have a DVT or PE

By selecting "I Agree to terms" on any of our digital communications confirms that:

• I have read and understand the information provided in this form, had all my questions answered, are knowledgeable about the conventional treatments available for my condition, and I am aware that some of the lab testing is not FDA approved and may be considered “unconventional”. NEXT|HEALTH is operating under FDA recognized EUA ( Emergency Use Authorization) for increased testing capability which are both recognized under high complex laboratory conditions.
• Long-term adverse consequences of any recommended therapies may be possible, but are unknown at this time.
• The provider has adequately explained the procedure set forth to me.
• I have received all the information and explanation I desire concerning the procedure.
• I authorize and consent to the performance of the procedure as agreed upon.
• I have discussed these treatments with my current physician and obtained his/her clearance if I desire.

You, the Patient, is fully accepting all responsibilities for the risks, the Patient, on behalf of himself/herself, his/her heirs, executors, administrators, and assigns hereby fully and completely releases Physician, his successors, and all of his employees, independent contractors, agents, officers, directors, representatives, affiliates and associations (“Released Parties”) from all claims and causes of action by reason of any complication, injury and/or damage which Patient may suffer as a result of any medical services or treatment provided by Released Parties at any time in the past or as a result of any new procedures.

1. Patient acknowledges and agrees that this release applies to all claims that Patient may have against Physician arising out of the above-described services or any services rendered at any time for injuries, damages, or losses, or for any other services provided in the past by any of the above mentioned “Released Parties”.
2. Patient warrants and represents that in executing this release, he/she has been given an opportunity to obtain legal advice from an attorney of his/her choice regarding the terms of this release and its consequences and that Patient fully understands the terms of this release.
3. Patient acknowledges and represents that in executing this release, he/she has not relied on any inducements, promises, or representations made by Physician or any party representing or serving Physician.
4. Patient acknowledges and warrants that his/her execution of this release is free and voluntary, and he/she fully understands this release.
5. Patient certifies that he/she has read Section 1542 of the Civil Code, set out below: A general release does not extend to claims which the creditor does not know or suspect to exist in his favor at the time of executing the release, which if known by him must have materially affected his settlement with the debtor.
6. Patient hereby waives application of Section 1542 of the Civil Code.
7. Patient understands and acknowledges that the significance and consequence of this waiver of Section 1542 of the Civil Code is that even if Patient should eventually suffer additional damages arising out of the above-described medical services and treatment he/she will not be permitted to make any claim for those damages. Furthermore, Patient acknowledges that he/she intends these consequences even as to claims for injury and/or damages that may exist as of the date of this release but which Patient does not know exist, and which, if known, would materially affect Patient's decision to execute this release, regardless of whether Patient's lack of knowledge is the result of ignorance, oversight, error, negligence, or any other cause.
9. For the safety of our customers and employees, training, and quality assurance purposes, it is
   the policy of Next Health that all public areas may be video and audio recorded. I understand and
10. acknowledge that audio and video recording for training and quality control purposes is taking place.  
11. By signing this consent, I hereby give consent to Next Health Management Group and all
12. Next Health entities for recording devices to be used.

By selecting "I Agree to terms" on any of our digital communications confirms that: You understand these risks/benefits/alternatives, and are willing to accept all risks.

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