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CONSENT FORM

PATIENT CONSENT FOR IV INFUSION AND INJECTION THERAPIES WITH RENEW MEDSPA WELLNESS
If you have any questions, please feel free to ask us. Please tick "Yes" acknowledging you understand that:

Renew Medspa Wellness

Please fill out the following form

If you are late or miss your appointment, you may be subject to a $50 fee.
Services must be paid for at the time of service.
Health insurance typically does not cover services provided at RENEW MEDSPA WELLNESS. If you want to seek insurance reimbursement, we would be happy to provide you itemized invoices that you can submit to your insurance company.
(IF YOU ARE ACCEPTING INSURANCE, UTILIZE THE STATEMENT BELOW INSTEAD)
Since each insurance company has its own policies regarding the coverage of procedures, I also acknowledge that I am responsible for payment in full for the charges incurred for procedures and treatment regardless of the coverage provided by my insurance carrier.
I understand that treatments used at RENEW MEDSPA WELLNESS might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life.
I agree that if I am having any side effects or become sick, that I will follow up with my primary care provider or go to an urgent care or emergency department.
I acknowledge that RENEW MEDSPA WELLNESS and (PROVIDER NAME) are not my primary care provider. I agree that I will continue with routine care through my primary care provider and notify them of treatments prescribed and performed at RENEW MEDSPA WELLNESS)
I understand that there are no refunds for services or products rendered.
I understand that having an appointment with RENEW MEDSPA WELLNESS does not necessarily entitle me to having an IV infusion or injection procedure performed. Every individual is different, and it is at the medical providers discretion to issue treatment.
I understand that I must maintain my follow up appointments and following post procedural care instructions to remain on treatment. It is important that (MEDICAL PROVIDER) manages my treatment and it is at their discretion to provide me ongoing therapies if desired.
I acknowledge that I have been advised of the risks and benefits of treatment. I also acknowledge that I have been advised of possible complications and side effects. I understand the risks, benefits, complications, and side effects of treatment.
I am voluntarily requesting treatment with RENEW MEDSPA WELLNESS and (PROVIDE NAME) in regard to IV infusion therapy and injection therapy as determined by a mutual decision between myself and the medical provider even if it is not considered a medical necessity.
I do not hold any medical practitioner of RENEW MEDSPA WELLNESS responsible for performing age-related preventive care. I agree that I will follow up with my primary care provider to obtain these screenings and I hold RENEW MEDSPA WELLNESS and (MEDICAL PROVIDER) harmless if an adverse event occurs during my treatment.

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