Intake Form - Stuart Aspinwall


Full Name:

Stuart

Address:

522 Vermont St

Phone Number:

910-581-7183

Email:

Sarahjo22659

Height:

6.3

Weight:

222

Sex:

DOB:

12/02/1982

Occupation:

Lawn care


Allergies:

None that we know of

Medications, OTC, Vitamins:

None

Medical Conditions/Diseases: (Please check all that apply)

Other (If other, please list below):

Are you pregnant or breastfeeding?

Do you expect to become pregnant, or start breastfeeding?

 


 

Do you use nitrates for chest pain?

Using Regenerative Medicine such as vitamin boosters, hormone replacement, and micronutrient therapy we can help you with mental and physical health, sexual vitality, prevention of disease, weight loss, and increased energy. For communication purposes, please check how you would like to be notified about appointments and Beverly Hills Concierge Doctor / The Cure IV offers.

 


Physician – Patient Arbitration Agreement

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California and federal law, and not by a lawsuit or resort to court process except as state and federal law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is also understood that any dispute that does not relate to medical malpractice, including disputes as to whether or not a dispute is subject to arbitration, will also be determined by submission to binding arbitration. It is the intention of the parties that this agreement bind all parties as to all claims, including claims arising out of or relating to treatment or services provided by the health care provider including any heirs or past, present or future spouse(s) of the patient in relation to all claims, including loss of consortium. This agreement is also intended to bind any children of the patient whether born or unborn at the time of the occurrence giving rise to any claim. 

All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the health care provider,  and/or the health care provider’s associates/ association, corporation, partnership, employees, agents and estate, must be arbitrated including without limitation, claims for loss of consortium, wrongful death, emotional distress, injunctive relief, or punitive damages.

Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days thereafter. The neutral arbitrator shall then be the sole arbitrator and shall decide the arbitration. Each party to arbitration incurred or approved by the neutral arbitrator, not including counsel fees, witness fees, or other expenses incurred by a party for such party’s own benefit. Either party shall have the absolute right to bifurcate the issues of liability and damage upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity that would otherwise be a proper additional party in a court action and upon such intervention and joinder, any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of the California Medical Injury Compensation Reform Act shall apply to disputes within this arbitration agreement, including, but not limited to, sections establishing the right to introduce evidence of any amount payable as a benefit to the patient as allowed by law (Civil Code 3333.1), the limitation on recovery for non-economic losses (Civil Code 3333.2), and the right to have a judgment for future damages conformed to periodic payments (CCP 667.7). The parties further agree that the Commercial Arbitration Rules of the American Arbitration Association shall govern any arbitration conducted pursuant to this Arbitration Agreement.

Article 4: General Provision: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable legal statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the health care provider within 30 days of signature and if not revoked will govern all professional services received by the patient and all other disputes between the parties.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (for example, emergency treatment) patient should initial here . Effective as of the date of first professional services.

If any provision of this Arbitration Agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this Arbitration Agreement. By my signature below, I acknowledge that I have received a copy.

NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION, AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.

CONSENT TO TREATMENT

This is to acknowledge that I have been informed and understand that: 

1. Intramuscular injections or intravenous vitamins are intended to promote health but may have side effects. While chances of experiencing complications are small, it is the practice of our clinic to inform patients about them. These complications may occur at the injection site and include, but are not limited to soreness in injection area, lumps, nodules, welts, blisters, discoloration, shooting pain in injection area, and or burning pain which may last up to 3 months post treatment including but not limited to discomfort, dull pain, mild swelling, bruising, dizziness, or temporary worsening of existing symptoms. 

By checking here you acknowledge this.

    

More serious complications are extremely rare but if you experience rash, shortness of breath, swelling in mouth, lips or face occur directly after injection, report to emergency care as soon as possible or call 911. Additional information on side effects and complications is available upon request.

By checking here you acknowledge this.

    

2. Intramuscular injections will be administered in one of two locations depending on your preference: deltoid muscle of right or left arm, or in dorso gluteal muscle on right or left hip. By checking here you acknowledge this.  Vitamin C injections will always be administered in the subcutaneous fat, usually in the abdomen area.   

3. For the purposes of an IV the vein in your arm will be punctured to allow the drip to occur. Sometimes due to complications with veins, multiple puncture may need to happen in order to successfully access the vein.  If you know of any past experiences where an IV you received failed or was difficult to administer, please disclose this to your nurse prior to treatment start so they may be best prepared for an ideal outcome and so they may take proper precautions. By checking here you acknowledge this.   

4. The puncture site of an IV or injection may bruise and leave pain for one to two weeks post treatment. 

5. Please do not move your arm once the IV has started.    

6. Do not bend your arm that has an IV attached otherwise the IV may become blocked and fail to administer. 

7. When the IV has finished, blood may draw back into the tube due to natural pressure/flow.  Do not become alarmed, you may raise your arm slightly to stop this.

Your healthcare provider will review procedure with you prior to injection. Please ask questions where they may arise. If you have any past experiences with needle phobia, fainting or heightened pain response, please notify practitioner prior to injection so they may take proper precautions. If your physician or nurse does not explain the procedure, its benefits and risks to your satisfaction, please ask for more information.    

Methylcobalamin, Hydroxycobalamin, or Cyanocobalamin will be used for B12 injections. Typically, those who receive B12 injections experience more energy which may cause difficulty sleeping at night if taken late in the day. If receiving B12 injection or intravenous therapy, it is recommended to have eaten prior to treatment, for B12 has the potential to cause nausea if administered on an empty stomach. Urine discoloration may occur due to pigment of vitamin(s). Mild detoxification reactions can occur, such as: increased fatigue, headache, increased muscle fatigue or cramping, and possible nausea, or change in bowel movements.    

I authorize Beverly Hills Concierge Doctor / The Cure Los Angeles to obtain a prescription from the medical doctor for the vitamins and medications rendered to me today or in the future.  

I have read and understand the above and have had the opportunity to ask questions. I hereby consent to treatment. 

Our IVs & injections are for healthy individuals. These IVs do not cure, treat or prevent any illness, health concern, condition, disease, etc. If you are considering an IV with us and have a serious, chronic or potentially fatal illness or diseases we reserve the right to refuse treatment. We do NOT claim to treat, cure or aid in prevention of any sickness, cancer or diseases. 

By signing below, you are hereby acknowledging that you have been notified of treatment costs and restrictions and confirm that you are electing our IV and vitamin treatments for the nutritional benefits only. 

Dear Clients,

We look forward to doing business with you. Please review our refund and purchase policies that apply to your purchases with us. Our Refund Policy is as follows: Payment for the full cost of services is non refundable. Cancellations will be accepted with 24 hours advanced notice. Once an IV bag is prepared for a treatment the full amount will be charged. If a patient is unfit to receive for treatment for any reason a $100 fee and any travel fees with be charged. 

Refunds / No Show Policy We understand that life may get in the way of your attendance to your booked appointment, however, no show appointments will be charged 100% of the appointment/service cost.  We reserve the right to deduct payment from your pre paid packages.

Patient Financial Responsibilities Agreement

Thank you for selecting Beverly Hills Concierge Doctor / The Cure Los Angeles. In order to prevent any misunderstanding concerning payment responsibilities regarding fees, below is a summary of your financial responsibilities:

Payment: You are responsible for your entire bill at the time of service including additional cost of any vitamins, supplements, or medications added on to treatment. 

Insurance: Beverly Hills Concierge Doctor / The Cure Los Angeles does not accept insurance and will not bill insurances on your behalf. However, upon request, we will provide you with an itemized statement for you to present to your insurance carrier if you wish to seek reimbursement. In many cases, the cost of products or services received at Beverly Hills Concierge Doctor / The Cure Los Angeles are not covered by insurance as they may be deemed elective prevention and well-being services. Beverly Hills Concierge Doctor / The Cure Los Angeles does not make any representations as to whether the products or services you received will be covered or reimbursed by your insurance company. If you have questions regarding coverage, you should contact your insurance company directly.

Change of Information: You are responsible to provide Beverly Hills Concierge Doctor / The Cure Los Angeles current contact information.

Additional Services: Please note that lab and other test services, such as blood, urine and saliva tests are additional costs, separate from the base service cost. If you have questions about the cost of an additional service(s), please ask a Beverly Hills Concierge Doctor / The Cure Los Angeles staff before the additional service is provided.

Appointment Cancellation Charge: If you cancel an appointment with less than 24 hours notice, or if you do not show up at your scheduled appointment, you will be charged a $200 cancellation fee. You will be given a 15 minute grace period. 

Form of Payment: Payments may be made in cash, by check, or by Visa, MasterCard, Discover or American Express, however we reserve the right to discontinue any of these payment methods.

Wait Time Fees: If you cannot start your appointment within 15 minutes of scheduled start time we are happy to have our nurse wait on the condition that it does not cause any scheduling conflicts. Wait time is charged at $100/ hour / nurse in increments of 15 minutes and start to accrue 30 minutes after the start of your appointment. 

By signing below, I acknowledge and agree that I have read, understood and agree to the terms set forth above, including, without limitation, that I am ultimately responsible for payment for all fees, regardless of insurance or other coverage.

Leave this empty:

Signed by Stuart Aspinwall
Signed on:November 6, 2018

Signature Certificate
Document name: Intake Form - Stuart Aspinwall
Unique Document ID: 737f02388c1ab55ad6895847472dd49be77d7dce
Stuart Aspinwall
Party ID: ada849ca-3d63-4b5b-bd84-fd7c121333e7
IP Address: 10.4.73.208
Digital Signature:
Multi-Factor
Digital Fingerprint Checksum
135b812f97c8d767c208f80fe7c3c587
Timestamp Audit
November 6, 2018 1:00 pm PDTIntake Form - Stuart Aspinwall Uploaded by Lindsay S - [email protected] IP 192.168.95.1, 172.17.0.1
November 6, 2018 1:00 pm PDTDocument signed by Stuart Aspinwall - [email protected] IP 172.58.94.131, 10.3.15.234
November 6, 2018 1:00 pm PDTDr. Ali - [email protected] added by Lindsay S - [email protected] as a CC'd Recipient Ip: 192.168.95.1, 172.17.0.1
November 6, 2018 1:00 pm PDTThe document has been signed by all parties and is now closed.