I understand that treatments used at Restorative Wellness, PLLC might not be considered a medical necessity. Treatments rendered are for the purpose of improving your quality of life through hormone restoration, nutritional, and supplemental counseling, and weight loss or weight maintenance treatment.
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 immediately.
I acknowledge that Restorative Wellness, PLLC and our providers 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 at Restorative Wellness, PLLC.
If your vial is damaged or mishandled or incorrect dose is administered resulting in running out early, you will need to cover the cost of additional medication up to a maximum of $500 depending on the medication and dose.
I understand that having an appointment with Restorative Wellness, PLLC does not necessarily entitle me to being issued a prescription for hormone replacement, weight loss medication, or additional medications. Every individual is different, and it is at the medical provider’s discretion to issue a prescription. If you are not prescribed a medication, the $50 initial visit fee is waived.
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 do not hold any medical practitioner of Restorative Wellness, PLLC 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 all providers of Restorative Wellness, PLLC harmless if an adverse event occurs during my treatment. I will ensure that my primary care provider provides the results of such screenings to Restorative Wellness, PLLC as this could change the treatment prescribed to me.
I understand that refunds of medicines are not offered under any circumstances as no healthcare provider can reasonably predict response, intolerance, or lack of response to any specific weight management or hormonal replacement treatment. Medications cannot be returned.
I agree to indemnify, defend, protect, and hold harmless the medical providers or staff employed or contracted by Restorative Wellness, PLLC and their respective officers, directors, employees, stockholders, assigns, successors and affiliates (Indemnified Parties) from, against and in respect of all liabilities, losses, claims, damages, judgements, settlement payments, deficiencies, penalties, fines, interest and costs, expenses suffered, sustained, incurred or paid by the indemnified parties, in connection with, results from or arising out of, directly or indirectly, the medical providers employed by Restorative Wellness, PLLC rendering medical care, services, advice, and/or treatment, my failure to disclose all relevant information regarding my medical and physical condition, acts or omissions, the medical providers employed or contracted by Restorative Wellness, PLLC ; harm or injury resulting from medical care or pharmaceuticals provided directly or indirectly by the medical providers employed by Restorative Wellness, PLLC. I am aware of the potential side effects associated with weight loss therapy, accept all the risks involved in taking the medication and will not seek indemnification or damages from the indemnified parties.