Z Medi Clinics and Z Medi Spa
Z Med Clinic and ZMedi Clinics Providers PA offers its patients a line of infusion therapies. While these therapies are generally administered intravenously (by IV), they may involve the administration drugs, nutrients, solvents, or other compounds orally, sublingually, topically, rectally, transdermal, inhaled, nebulized, subcutaneously, or intramuscularly.
YOU ARE ADVISED THAT MANY INFUSION THERAPIES OFFERED BY THE CLINIC ARE NOT YET APPROVED BY THE US FOOD & DRUG ADMINISTRATION (FDA), FOR ANY PURPOSE OR FOR THE PURPOSE THAT YOU MAY SEEK.
You are encouraged to raise questions you have about the therapies with the medical staff.The Clinic and affiliated physicians and mid-level healthcare practitioners do not perform infusion therapies without the patients informed consent, authorization for the treatment, and release of our legal liability, which you indicate by signing this form, along with your election to undergo the infusion therapies.
The infusion therapies offered by the Clinic, including the location where you receive this form can generally be described as follows:
- Intravenous Vitamin C to stimulate immunity and healing;
- Myers Cocktail to reduce inflammation and overcome fatigue
- Weight Loss to help detox bad toxins out the body
- Nutrition Therapy to boost energy and general well-being.
- Lyme Disease
- Herpes Simplex Virus Therapy
Again, you are directed to address any particular questions or concerns you have with our physicians or mid-level healthcare practitioners (nurse practitioners or physicians assistants).
Benefits of intravenous therapy include, but not limited to:
- The full dose of infusion is available to tissues.
- Digestive conditions do not affect absorption.
- High concentrations can be achieved, forcing nutrients into the cells.
- Intestinal irritation that sometimes occurs with oral administration is avoided.
Risks of intravenous therapy may include the following, but not limited to:
- Pain or bruising at the injection site,
- Inflammation of the vein used for injection, and
- Severe allergic reaction, anaphylaxis, cardiac arrest, or death.
The Clinic and affiliated physicians and mid-level healthcare practitioners only perform these therapies at your request as our patient, and only after you have been informed about the therapies through information we provide, through your own research, and through inquiry you may raise with our medical staff. BY SIGNING BELOW, YOU ACKNOWLEDGE HAVING BEEN INFORMED TO YOUR SATISFACTION ON THE PROPOSED THERAPIES. YOU VOLUNTARILY ELECT TO UNDERGO THEM, AND YOU AUTHORIZE THEIR PERFORMANCE.YOU ASSUME THE RISK ASSOCIATED WITH USING THIS TREATMENT.YOU FURTHER RELEASE AND AGREE TO INDEMNIFY AND HOLD HARMLESS THE CLINIC AND ANY OF ITS DIRECTORS, OFFICERS, PARENTS, SUBSIDIARIES, EMPLOYEES, AGENTS, OR VOLUNTEERS FOR LIABILITY FROM ANY BODILY INJURY, PROPERTY DAMAGE, OR OTHER LOSS INCURRED FROM PERFORMANCE OF THE THERAPIES, EVEN THOUGH CAUSED IN WHOLE OR IN PART BY A PRE-EXISTING DEFECT, THE NEGLIGENCE (WHETHER SOLE, JOINT, OR CONCURRENT), GROSS NEGLIGENCE, STRICT LIABILITY, OR OTHER LEGAL FAULT OF THE CLINIC OR ITS ACTORS.
Patient Payment Agreement:
I agree to pay 50 % of the cost of supplies, medication and/or supplements in advance,before starting my treatment.
Cancellation Policy:
I understand if I do not CANCEL or RESCHEDULE my appointment within 24 hours of my scheduled consultation, there will be a fee of 50% of the cost of the visit. For a scheduled IV Infusion, I must call 281-955-0000 by 8:00 a.m. on the day of the designated appointment or the full cost of the session will be charged. (Messages left before 8:00 a.m. will be acknowledged). Treatments are individually mixed and cannot be used on a different patient. If you have questions about our cancellation policy please asks the front desk for clarification.
