New Patient Forms

By completing the necessary consent forms, you acknowledge and authorize the healthcare provider to handle and disclose your protected health information (PHI) in accordance with HIPAA regulations. This ensures the privacy and security of your personal data during treatment, payment, and healthcare operations. Additionally, the consent forms for IV hydration therapy and intramuscular injections outline the purpose, potential benefits, risks, and possible side effects associated with these procedures. By signing these forms, you provide your informed consent, understanding the importance of accurate medical information for safe and effective treatment.

HIPAA Patient Consent Form

Telemedicine Informed Consent Form

Personal Information Authorization

IM Injection Medical Consent Form

IV Hydration Medical Consent Form

"*" indicates required fields

HIPAA Patient Consent Form

IVMEUP, PC

The Health Insurance Portability and Accountability Act of 1996, and subsequent amendments, (collectively “HIPAA”), allows for the use and disclosure of certain patient protected health information (“PHI”) for purposes of treatment, payment, or healthcare operations, and provides standards for patient rights and safeguards related to such information’s use or disclosure by healthcare providers, such as IVMEUP, PC, (the “Practice”).

Our Notice of Privacy Practices (the “Notice”) provides information about how we may use or disclose your PHI, and your rights to access and amend your PHI under HIPAA. The terms of the Notice may change from time to time, and if so, you will be notified and/or provided with an updated copy of the Notice upon your request.

We may use your information to contact you for scheduling appointments, payment, in an emergency, or in other ways permitted or required by law. We will not market, sell, or disclose your information to third-parties unless we ask for and receive your written permission to do so through an authorization made by you. We are required by law to maintain the privacy and security of your PHI and will notify you in the event of a breach of your PHI.

By signing this form, you consent to our use and disclosure of your PHI for treatment, payment, other reasons permitted by law, and the means by which to contact you. You have the right to revoke this consent in writing signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand the following key information regarding my PHI:

My PHI may be disclosed or used for the reasons set forth above.
I must provide separate authorization for the Practice to use or share my PHI for other reasons.
I have received and read the Notice of Privacy Practices.
The Practice reserves the right to change the Notice as allowed by law.
I/the Patient have/has the right to revoke this consent in writing at any time.
I will be informed if a breach of my PHI occurs.

May we phone, email or send a text to you to confirm/update you for appointments?*

Yes

No

May we leave a message on your answering machine at home or on your cell phone?*

Yes

No

You acknowledge by your signature below that you have reviewed our Notice and understand and consent to the uses and disclosures of your PHI and your rights related to your PHI under HIPAA as set forth herein:

Patient/Guardian Signature*

Patient/Guardian Name*

"*" indicates required fields

IVMEUP, PC

Informed Consent for Telemedicine Services

CONSENT FOR TELEMEDICINE:

Telemedicine Introduction:

Telemedicine involves the use of electronic communications to enable Health Professionals at different locations (the “Telemedicine Providers”) to share individual patient medical information for the purpose of improving patient care (“Telemedicine”). The information may be used for diagnosis, consultation, treatment and/or follow-up and may consist of:

Patient medical records and/or medical images (i.e., store and forward); and
Live two-way audio and visual communications.

Electronic systems used will incorporate security protocols and safeguard measures to protect the confidentiality of patient identification and data and to ensure its integrity against corruption.

Expected Benefits of Telemedicine

Improved access to medical care by enabling a patient to remain at a remote site while the Provider obtains test results and consults with Telemedicine Providers at distant/other sites;
More efficient medical evaluation and management; and
Expertise of a distant specialist Telemedicine Provider.

Possible Risks of Telemedicine

As with any medical procedure, there are potential risks associated with the use of Telemedicine. These risks include, but may not be limited to:

In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the Telemedicine Provider;
Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment, which could result in the Telemedicine Provider’s inability to complete the evaluation and/or prescription process;
In very rare instances, security protocols could fail, causing a breach of privacy of personal health information; or
In very rare cases, a lack of access to complete medical records may result in adverse drug interactions or allergic reactions or other judgment errors.

CONSENT FOR TELEMEDICINE ACKNOWLEDGEMENT:

I acknowledge that I have been informed about, understand and have been given the opportunity to ask any questions regarding the following information:

A limited physical examination may take place during the Telemedicine services and I can ask the Telemedicine Provider to discontinue the interaction at any time. Some parts of the exam may also be conducted by individuals at my location at the direction of the Telemedicine Provider and others may be present to operate the equipment.

The laws that protect privacy and confidentiality of medical information also apply to the Telemedicine services.

All existing laws regarding patient access to and copies of health records apply to the Telemedicine services. I have the right to inspect all information obtained and recorded in the course of the Telemedicine services, and may receive copies of this information for a reasonable fee.

I understand that Telemedicine may involve electronic communication of my personal medical information to other medical practitioners and ancillary service providers.

I understand that I have the option to withhold or withdraw my consent for the use of the Telemedicine services in the course of my care at any time, without affecting my right to future care or treatment.

Patients under care of Naficy Medical Group: I have been informed that Neda Tahami, PA-C works at Naficy Medical Group and is part owner of IV ME UP.

Signature of Participant*

Name of Participant*

"*" indicates required fields

MEDICAL CONSENT, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT

I hereby acknowledge that I have voluntarily elected to participate in IM injection (the "Procedure") and in consideration for being permitted to participate in the Procedure, I hereby acknowledge and agree to the following:

ELECTIVE PARTICIPATION: I acknowledge that my participation is elective, and that the Procedure is deemed experimental, as it has not been approved by the U.S. Food and Drug Administration (“FDA”) and has not been studied for safety or efficacy in clinical trials.

INFORMED CONSENT: I have been informed of and I understand the purpose and nature of the Procedure. I understand that as a Participant in the Procedure I could sustain serious personal injuries, or illness as a consequence of not only IVMEUP, PC (“Participating Clinic”) actions, inactions or negligence, but also the actions, inactions or negligence of others, conditions of equipment used, and that there may be other risks not known to me or not reasonably foreseeable at this time. I further understand and agree that any injury, illness, disability that I may sustain by any means is my sole responsibility.

Patients under care of Naficy Medical Group: I have been informed that Neda Tahami, PA-C works at Naficy Medical Group and is part owner of IV ME UP.

ASSUMPTION OF RISK: I understand that there are potential dangers incidental to my participation in the Procedure, some of which may expose me to the risk of personal injuries. I understand that these potential risks may include other risks which are unknown at this time including:

redness, burning or stinging at the insertion site, swelling at the insertion site
bruising at the insertion site
allergic reaction
palpitations
infiltration or phlebitis at the insertion site, or infection at the insertion site

I am not pregnant nor am I under the influence of alcohol or illicit drugs.

I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF RELEASEES, and assume full responsibility for my participation in the Program at any such Participating Clinic.

INDEMNITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, agree to hold harmless, defend and indemnify the Releasees from any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys' fees), arising from any injury, property damage or death that I may suffer as a result of my participation in the Procedure, REGARDLESS OF WHETHER THE INJURY, OR DAMAGE IS CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.

CHOICE OF LAW/SEVERABILITY: I hereby agree that this Agreement shall be construed in accordance with the laws of the State of California and that this Agreement is intended to be as broad and inclusive as permitted by such state and federal laws. I further agree that if any portion hereof is held invalid, the balance shall, notwithstanding, continue in full force and effect.

HEALTH/SAFETY RISK: I am aware of all applicable personal medical needs, and I am unaware of any health-related reasons or problems which preclude or restrict my participation in the Procedure. I have arranged, through insurance or otherwise, to meet any and all needs for payment of medical costs while I participate in the Procedure. I understand and agree that Participating Clinic is not obligated to attend to any of my medical or medication needs during the Procedure, and I assume all risk and responsibility therefor. If during the Procedure I require medical treatment or hospital care, in a foreign country or in the United States, Participating Clinic is not responsible for the costs or quality of such treatment or care. I agree that Participating Clinic may, but is not obligated to, take any actions it considers necessary under the circumstances regarding my health and safety. I further agree to pay all expenses relating thereto and release Participating Clinic from any liability for any actions it may take.

I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES CONSENT TO EXPERIMENTAL TREATMENT, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I UNDERSTAND THAT I HAVE WAIVED LEGAL RIGHTS BY SIGNING THIS AGREEMENT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT OR COERCION AND ACCEPT ALL RISK AND RESULTING FROM THE PROCEDURE.

Signature of Participant*

Name of Participant*

Email*

"*" indicates required fields

MEDICAL CONSENT, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT

I hereby acknowledge that I have voluntarily elected to participate in IV Hydration Therapy (the "Procedure") and in consideration for being permitted to participate in the Procedure, I hereby acknowledge and agree to the following:

ELECTIVE PARTICIPATION: I acknowledge that my participation is elective, and that the Procedure is deemed experimental, as it has not been approved by the U.S. Food and Drug Administration (“FDA”) and has not been studied for safety or efficacy in clinical trials.

INFORMED CONSENT: I have been informed of and I understand the purpose and nature of the Procedure. I understand that as a Participant in the Procedure I could sustain serious personal injuries, illness, or even death as a consequence of not only IVMEUP, PC (“Participating Clinic”) actions, inactions or negligence, but also the actions, inactions or negligence of others, conditions of equipment used, and that there may be other risks not known to me or not reasonably foreseeable at this time. I further understand and agree that any injury, illness, disability, or death that I may sustain by any means is my sole responsibility.

Patients under care of Naficy Medical Group: I have been informed that Neda Tahami, PA-C works at Naficy Medical Group and is part owner of IV ME UP.

ASSUMPTION OF RISK: I understand that there are potential dangers incidental to my participation in the Procedure, some of which may expose me to the risk of personal injuries, or even death. I understand that these potential risks may include other risks which are unknown at this time including:

redness, burning or stinging at the insertion site, swelling at the insertion site
bruising at the insertion site
allergic reaction
dizziness
infiltration or phlebitis at the insertion site, or infection at the insertion site

I further understand that the presence of alcohol, prescription medication, or other drugs in the body while participating in the procedure may increase the risk of potential harm including personal injuries, or even death. I am not pregnant nor am I under the influence of alcohol or illicit drugs.

I KNOWINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF RELEASEES, and assume full responsibility for my participation in the Program at any such Participating Clinic.

INDEMNITY: I, on behalf of myself, my personal representatives, heirs, executors, administrators, agents, and assigns, agree to hold harmless, defend and indemnify the Releasees from any and all liability, including any and all claims, demands, causes of action (known or unknown), suits, or judgments of any and every kind (including attorneys' fees), arising from any injury, property damage or death that I may suffer as a result of my participation in the Procedure, REGARDLESS OF WHETHER THE INJURY, DAMAGE OR DEATH IS CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE.

CHOICE OF LAW/SEVERABILITY: I hereby agree that this Agreement shall be construed in accordance with the laws of the State of California and that this Agreement is intended to be as broad and inclusive as permitted by such state and federal laws. I further agree that if any portion hereof is held invalid, the balance shall, notwithstanding, continue in full force and effect.

HEALTH/SAFETY RISK: I am aware of all applicable personal medical needs, and I am unaware of any health-related reasons or problems which preclude or restrict my participation in the Procedure. I have arranged, through insurance or otherwise, to meet any and all needs for payment of medical costs while I participate in the Procedure. I understand and agree that Participating Clinic is not obligated to attend to any of my medical or medication needs during the Procedure, and I assume all risk and responsibility therefor. If during the Procedure I require medical treatment or hospital care, in a foreign country or in the United States, Participating Clinic is not responsible for the costs or quality of such treatment or care. I agree that Participating Clinic may, but is not obligated to, take any actions it considers necessary under the circumstances regarding my health and safety. I further agree to pay all expenses relating thereto and release Participating Clinic from any liability for any actions it may take.

I HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS. I AM AWARE THAT THIS AGREEMENT INCLUDES CONSENT TO EXPERIMENTAL TREATMENT, AN ASSUMPTION OF RISK, AND AN AGREEMENT TO INDEMNIFY THE RELEASEES. I UNDERSTAND THAT I HAVE WAIVED LEGAL RIGHTS BY SIGNING THIS AGREEMENT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT OR COERCION AND ACCEPT ALL RISK AND RESULTING FROM THE PROCEDURE.

Signature of Participant*

Name of Participant*

"*" indicates required fields

Authorization to Release and Disclose Personal Information

I, the undersigned, 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 IV ME UP, its healthcare providers and staff (collectively, “Provider”) and I understand that Provider stores Personal Information (defined below) about me, which will be part of my medical record. “Personal Information” includes but is not limited to 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.

Provider desires to utilize the Photography, and Patient agrees that the Photography may be used 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 Provider’s website and social media platforms (“Social Media”) and including such use in the Provider’s email marketing campaigns. In addition, Provider desires to have the right to interview, consult with and examine me at such times as Provider may reasonably request before, during and after my treatment, and Patient agrees that Provider shall have the right to use such interviews, consultations, or examinations on Social Media.

Patient agrees that the foregoing uses may incidentally disclose Personal Information related to my treatment, condition, procedure, or other information associated with such use, and I authorize such disclosure. Provider IS NOT receiving direct or indirect remuneration from a third party in connection with the use/disclosure of my personal information described in this authorization.

Patient understands that, except as otherwise provided in this authorization, Provider may use or disclose my personal information in accordance with Provider’s Notice of Privacy Practices. I understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected, if at all protected, by the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”) or other applicable laws or regulations.

This authorization is valid until the earlier or the occurrence of the death of Patient; Patient reaching the age of majority; or revocation by patient. I understand that a revocation is not effective to the extent that Provider has relied on the use or disclosure of Patient’s Photography or Personal Information, however, I understand that I have the right to revoke this authorization, in writing, at any time by sending such written notification to Provider’s privacy officer at the following address or to the following email address:

Address: 3857 Birch Street, Suite 3020, Newport Beach, CA 92660
Email: info@ivmeup.com

I understand Provider does not condition treatment or payment on the signing of this form. I understand that I will not be entitled to any payment or other form of remuneration from Provider as a result of any use of Photography or Personal Information.

Patient hereby agrees to release, discharge and hold harmless Provider from any and all rights, claims, defenses, causes of action, liabilities, losses, damages and costs that Patient may have had at any time in the past, currently or at any time in the future, of any nature whatsoever by reason of or arising out of, use and disclosure of Patient’s Photography or Personal Information. Patient further agrees that if, despite this authorization, Patient, or anyone on Patient’s behalf, makes a claim against Provider, Patient will indemnify, save, defend and hold harmless Provider from any litigation expenses, attorney fees, loss, liability, damage, or cost incurred as the result of such claim.

Patient/Patient’s Representative Signature*

Patient/Patient’s Representative*

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