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Please take a moment to complete the information below in order to allow us to evaluate you for care. 

Please select who is the patient today
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First Patient Name

First Name*

Last Name*

Phone*
First Patient Date of Birth*
First Patient Information

Reason for your visit today *
Location of Services*
Are you in generally in overall good health?*

When was your last physical? *

List any known allergies

List all medications you are taking (prescription and OTC):
Check ALL that pertain to you? It is vitally important that you read each option and provide detail as requested: *
Pregnant
Attempting to Become Pregnant
Breastfeeding
Cardiac Arrhythmias
Cardiac Surgery within the Last 3 Months
Congestive Heart Failure (CHF)
Coronary Artery Disease (CAD)
Chronic Kidney Disease (CKD)
Myocardial Infarction (MI) (heart attack) within the Last 3 Months
Kidney Failure
Liver Disease
Hemochromatosis (Iron Overload)
Anemia
Currently taking digoxin or potassium wasting diuretics
Currently Taking Lithium, Antiplatelet agents, Anticoagulants, Chronic use of NSAIDS or Thrombolytics
Currently on an anticancer drug called bortezomib
Diabetes
G6PD Deficiency
None of these Options Pertain To Me

If yes to any of the above, please describe

Are there any other medical conditions, concerns or lifestyle patterns we should be made aware?

Please list any substances that irritate your skin

We have a lot of patients come in for post-COVID fatigue. Providing the information below allows our team to better assist you and future patients.

Have you tested positive for COVID-19 within the past 6 months?*

If yes, approx how far post COVID are you? This info helps me us know how we can help you.

What symptoms are you still experiencing that are direct result of COVID? (ie: fatigue, brain fog, breathing issues, etc.)

Do you know which products/services you are interested in already?
To the best of my knowledge, the information provided above is true and accurate. I agree to tell the staff of any changes to my health history or medications as they arise. I understand that information is necessary for your practice and will remain confidential. All efforts are routinely made to ensure privacy is upheld.*
I ACKNOWLEDGE THIS ACCOUNT IS SELF-PAY, AND PAYMENT IN FULL IS DUE AT THE TIME OF EACH SERVICE. I clearly understand and agree that all services rendered to me will be charged directly to me, and that I am personally responsible for full payment. I understand that even if I suspend or terminate treatment, any fees for professional services rendered to me up to the point of termination will be immediately due and payable. Any other arrangements that may involve payment plan or payment deferral must be made in writing with the office manager or business manager of the Practice. Verbal agreements are not acceptable. I acknowledge that I am responsible for any outstanding fees for services provided to me by Southern Specialty Care, LLC dba Infu-Zen Spa ("Practice").*
PATIENT CONSENT TO TREATMENT - PLEASE READ EACH SECTION CAREFULLY. BY CHOOSING YES, I CONSENT TO TREATMENT I do hereby request and consent to an evaluation and treatment by Southern Specialty Care, LLC dba Infu-Zen Spa and its staff ("Practice"). I wish to rely on the Practice to exercise judgment for my best interest, the below-named patient, during the course of treatment. I will inform the Practice of any sensitive areas or adverse conditions that I may have had prior to, during or after treatment. I intend this consent to cover the entire course of treatment. I understand that any questions I may have regarding the potential side effects, complications, treatment or treatment area may be directed to the attending Practice staff member during my evaluation and course of treatment. I understand that the practice of medicine and surgery is not an exact science. I further understand and accept that fees are paid for performance of medical services only, and not a guaranteed result. I acknowledge by my signature below that although a good outcome is expected, and a reasonable effort has been made to establish realistic expectations, there cannot be any warranty, expressed or implied, as to the results that may be obtained. I acknowledge that I am voluntarily participating in intramuscular injections and intravenous infusion therapy and am doing so at my own risk. I understand that there may be adverse side effects, reactions (including but not limited to pain, swelling or bruising of the injection site.) I request and consent to be transported by Practice staff and/or emergency medical services to a hospital or emergency medical facility in the event of a medical emergency during the course of my treatment at the Practice.*
PATIENT CONSENT TO TELEMEDICINE SERVICES - BY CHOOSING YES, I CONSENT TO TELEMEDICINE SERVICES Introduction: Telemedicine involves the real-time evaluation, diagnosis, consultation on and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real time. There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand I can ask questions and seek clarification of the procedures and telemedicine technology at any time. Consent for treatment: I voluntarily request Southern Specialty Care, LLC dba Infu-Zen Spa and its physicians, nurses, associates, technical assistants and other health care providers as it may deem necessary (collectively "Practice") to participate in my medical care through the use of telemedicine. I understand that Practice (i) may practice in a different location than where I present for medical care, (ii) may not have the opportunity to perform an in-person physical examination, and (iii) rely on information provided by me. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I further acknowledge my failure to accurately and completely relay information about my medical history, condition and care may adversely impact Practice's advice, recommendations or decisions about my care. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure. I understand that if Practice determines in its reasonable professional judgment that telemedicine services will not adequately address my medical needs, I may be required to complete an in-person medical evaluation. I also understand that in the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented, or an in-person medical evaluation may be necessary. Finally, if I experience an urgent matter after a telemedicine session, such as a bad reaction to a treatment, I should alert my treating physician and, in the case of emergencies, dial 911 or go to the nearest hospital emergency department. Release of information: To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of my Personal Information (defined below) to Practice. I understand this disclosure may include my name, address, contact and demographic information, general health status and treatment information, images, individually identifiable health information or protected health information, and other information related to my health or condition (collectively "Personal Information"). I understand that the disclosure of my Personal Information to Practice, including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering. Right to withdraw consent: I understand that I have the right to withdraw my consent to the use of telemedicine in the course of my care at any time. I have read this Telemedicine Consent in its entirety and agree to be bound by all of its terms and conditions as described above. I acknowledge and agree that I have been given the opportunity to ask any questions and have either (i) declined the opportunity to do so, or (ii) had all my questions answered to my satisfaction.*
CONSENT FOR PHOTOGRAPHY - PLEASE CHECK ALL THAT APPLY: As the patient identified or the legal representative of such patient ("Patient"), have consented to the taking of photographs, videotapes, digital or audio recordings, and/or images of Patient, and any other method to reproduce or edit such Patient's likeness or image now known or hereafter developed (collectively, "Photography"), by Southern Specialty Care, LLC dba Infu-Zen Spa and its staff (collectively "Practice") which will be part of my medical record. I also understand that the Photography that identify Patient can be released and/or used outside the Practice only upon written authorization from me. The Practice desires to utilize the Photography for purposes of professional publications, training, education, or clinical evaluation as well as on social media, including posting on social media accounts, including, but not limited to the Practice's website and social media platforms ("Social Media") and including such use in the Practice's email marketing campaigns, both of which will result in the publication and distribution of protected health information to the general public. The Practice IS NOT receiving direct or indirect remuneration from a third party in connection with the use/disclosure of the protected health information described in this authorization.
I authorize Infu-Zen Spa to take and retain pictures for my medical file.
I authorize Infu-Zen Spa to use pictures for purposes of social media and/or advertising
First Patient Signature*
Patient Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*
Check to receive information, news, and discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
How did you hear about Infu-Zen Spa *
Referral from a Friend
Search Engine (Google, Bing, etc)
Social Media
Print Advertisement
Walk-In
BNI
Chamber of Commerce
Other

If Search Engine (Google) What were you searching?

If Referral from a Friend, Please let us know who we can thank :)

If Other, please describe
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Reason for your visit today *
Location of Services*
Are you in generally in overall good health?*

When was your last physical? *

List any known allergies

List all medications you are taking (prescription and OTC):
Check ALL that pertain to you? It is vitally important that you read each option and provide detail as requested: *
Pregnant
Attempting to Become Pregnant
Breastfeeding
Cardiac Arrhythmias
Cardiac Surgery within the Last 3 Months
Congestive Heart Failure (CHF)
Coronary Artery Disease (CAD)
Chronic Kidney Disease (CKD)
Myocardial Infarction (MI) (heart attack) within the Last 3 Months
Kidney Failure
Liver Disease
Hemochromatosis (Iron Overload)
Anemia
Currently taking digoxin or potassium wasting diuretics
Currently Taking Lithium, Antiplatelet agents, Anticoagulants, Chronic use of NSAIDS or Thrombolytics
Currently on an anticancer drug called bortezomib
Diabetes
G6PD Deficiency
None of these Options Pertain To Me

If yes to any of the above, please describe

Are there any other medical conditions, concerns or lifestyle patterns we should be made aware?

Please list any substances that irritate your skin

We have a lot of patients come in for post-COVID fatigue. Providing the information below allows our team to better assist you and future patients.

Have you tested positive for COVID-19 within the past 6 months?*

If yes, approx how far post COVID are you? This info helps me us know how we can help you.

What symptoms are you still experiencing that are direct result of COVID? (ie: fatigue, brain fog, breathing issues, etc.)

Do you know which products/services you are interested in already?
To the best of my knowledge, the information provided above is true and accurate. I agree to tell the staff of any changes to my health history or medications as they arise. I understand that information is necessary for your practice and will remain confidential. All efforts are routinely made to ensure privacy is upheld.*
I ACKNOWLEDGE THIS ACCOUNT IS SELF-PAY, AND PAYMENT IN FULL IS DUE AT THE TIME OF EACH SERVICE. I clearly understand and agree that all services rendered to me will be charged directly to me, and that I am personally responsible for full payment. I understand that even if I suspend or terminate treatment, any fees for professional services rendered to me up to the point of termination will be immediately due and payable. Any other arrangements that may involve payment plan or payment deferral must be made in writing with the office manager or business manager of the Practice. Verbal agreements are not acceptable. I acknowledge that I am responsible for any outstanding fees for services provided to me by Southern Specialty Care, LLC dba Infu-Zen Spa ("Practice").*
PATIENT CONSENT TO TREATMENT - PLEASE READ EACH SECTION CAREFULLY. BY CHOOSING YES, I CONSENT TO TREATMENT I do hereby request and consent to an evaluation and treatment by Southern Specialty Care, LLC dba Infu-Zen Spa and its staff ("Practice"). I wish to rely on the Practice to exercise judgment for my best interest, the below-named patient, during the course of treatment. I will inform the Practice of any sensitive areas or adverse conditions that I may have had prior to, during or after treatment. I intend this consent to cover the entire course of treatment. I understand that any questions I may have regarding the potential side effects, complications, treatment or treatment area may be directed to the attending Practice staff member during my evaluation and course of treatment. I understand that the practice of medicine and surgery is not an exact science. I further understand and accept that fees are paid for performance of medical services only, and not a guaranteed result. I acknowledge by my signature below that although a good outcome is expected, and a reasonable effort has been made to establish realistic expectations, there cannot be any warranty, expressed or implied, as to the results that may be obtained. I acknowledge that I am voluntarily participating in intramuscular injections and intravenous infusion therapy and am doing so at my own risk. I understand that there may be adverse side effects, reactions (including but not limited to pain, swelling or bruising of the injection site.) I request and consent to be transported by Practice staff and/or emergency medical services to a hospital or emergency medical facility in the event of a medical emergency during the course of my treatment at the Practice.*
PATIENT CONSENT TO TELEMEDICINE SERVICES - BY CHOOSING YES, I CONSENT TO TELEMEDICINE SERVICES Introduction: Telemedicine involves the real-time evaluation, diagnosis, consultation on and treatment of a health condition using advanced telecommunications technology, which may include the use of interactive audio, video or other electronic media. As such, telemedicine allows the provider to see and communicate with the patient in real time. There are potential risks to this technology, including interruptions, unauthorized access and technical difficulties. I understand I can ask questions and seek clarification of the procedures and telemedicine technology at any time. Consent for treatment: I voluntarily request Southern Specialty Care, LLC dba Infu-Zen Spa and its physicians, nurses, associates, technical assistants and other health care providers as it may deem necessary (collectively "Practice") to participate in my medical care through the use of telemedicine. I understand that Practice (i) may practice in a different location than where I present for medical care, (ii) may not have the opportunity to perform an in-person physical examination, and (iii) rely on information provided by me. I acknowledge that it is my responsibility to provide information about my medical history, condition and care that is complete and accurate to the best of my ability. I further acknowledge my failure to accurately and completely relay information about my medical history, condition and care may adversely impact Practice's advice, recommendations or decisions about my care. I understand that the practice of medicine is not an exact science and that no warranties or guarantees are made to me as to result or cure. I understand that if Practice determines in its reasonable professional judgment that telemedicine services will not adequately address my medical needs, I may be required to complete an in-person medical evaluation. I also understand that in the event the telemedicine session is interrupted due to a technological problem or equipment failure, alternative means of communication may be implemented, or an in-person medical evaluation may be necessary. Finally, if I experience an urgent matter after a telemedicine session, such as a bad reaction to a treatment, I should alert my treating physician and, in the case of emergencies, dial 911 or go to the nearest hospital emergency department. Release of information: To facilitate the provision of care and/or treatment through telemedicine, I voluntarily request and authorize the disclosure of my Personal Information (defined below) to Practice. I understand this disclosure may include my name, address, contact and demographic information, general health status and treatment information, images, individually identifiable health information or protected health information, and other information related to my health or condition (collectively "Personal Information"). I understand that the disclosure of my Personal Information to Practice, including the audio and/or video, will be by electronic transmission. Although precautions are taken to protect the confidentiality of this information by preventing unauthorized review, I understand that electronic transmission of data, video images and audio is new and developing technology and that confidentiality may be compromised by failures of security safeguards or illegal and improper tampering. Right to withdraw consent: I understand that I have the right to withdraw my consent to the use of telemedicine in the course of my care at any time. I have read this Telemedicine Consent in its entirety and agree to be bound by all of its terms and conditions as described above. I acknowledge and agree that I have been given the opportunity to ask any questions and have either (i) declined the opportunity to do so, or (ii) had all my questions answered to my satisfaction.*
CONSENT FOR PHOTOGRAPHY - PLEASE CHECK ALL THAT APPLY: As the patient identified or the legal representative of such patient ("Patient"), have consented to the taking of photographs, videotapes, digital or audio recordings, and/or images of Patient, and any other method to reproduce or edit such Patient's likeness or image now known or hereafter developed (collectively, "Photography"), by Southern Specialty Care, LLC dba Infu-Zen Spa and its staff (collectively "Practice") which will be part of my medical record. I also understand that the Photography that identify Patient can be released and/or used outside the Practice only upon written authorization from me. The Practice desires to utilize the Photography for purposes of professional publications, training, education, or clinical evaluation as well as on social media, including posting on social media accounts, including, but not limited to the Practice's website and social media platforms ("Social Media") and including such use in the Practice's email marketing campaigns, both of which will result in the publication and distribution of protected health information to the general public. The Practice IS NOT receiving direct or indirect remuneration from a third party in connection with the use/disclosure of the protected health information described in this authorization.
I authorize Infu-Zen Spa to take and retain pictures for my medical file.
I authorize Infu-Zen Spa to use pictures for purposes of social media and/or advertising
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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