Sameday consent form
COVID -19 TESTING AUTHORIZATION
Please do not use our services until you have first read this COVID-19 Testing Authorization and Consent and subsequently made an informed decision that our services are right for you.
BACKGROUND ON OUR SERVICES: Praesidium, together with our affiliated laboratories,is pleased to facilitate COVID-19 testing. This includes the performance of testing by various means (including nasal swab specimens) by individuals who have opted-in for COVID-19 testing (hereinafter “COVID-19 testing”). Following processing of tested specimens, we will notify you of COVID-19 testing results.
CONSENT TO COVID-19 TESTING: You hereby agree to undergo COVID-19 testing in accordance with the instructions provided to you, including cooperation with all healthcare professionals and personnel to collect an appropriate specimen safely and effectively. You agree to comply with all instructions provided to you related to administration of the COVID-19 testing kit. You further acknowledge that the COVID-19 testing kit is available as a result of the U.S. Food and Drug Administration’s Emergency Use Authorization (“EUA”) process under section 564 of the Federal Food, Drug, and Cosmetic Act. EUAs make available diagnostic and therapeutic medical devices to diagnose and respond to public health emergencies by allowing unapproved medical products or unapproved uses of approved medical products to be used in an emergency to diagnose, treat, or prevent serious or life-threatening diseases or conditions caused by chemical, biological, radiological and nuclear threat agents when there are no adequate, approved, and available alternatives. As a result, the COVID-19 testing kit is subject to certain limitations. You understand that as with any type of medical or health related test, procedure or treatment, certain risks apply. COVID-19 testing risks include the risk of injury as the result of administering the test; the risk of improper administration; and inaccurate test results.
In addition to the foregoing you acknowledge the following:
RISKS OF DISCOMFORT: Testing may involve discomfort, including pain, tearing up, and/or triggering a gag reflux.
RISK OF INACCURACY: There is a risk the test will result in a false positive or false negative result, and a positive or negative test result does not mean there are no additional possible adverse health conditions or outcomes I may experience.
RISK OF EXPOSURE: Being present in the same space as others, despite my own efforts and those of the health professionals working with me, may increase the risk of my exposure to COVID-19 and the novel coronavirus (SARS-CoV-2). Even following best practices, it is possible for me and Provider personnel to be unaware that we are contagious even without symptoms, raising the possibility of infection. I am aware that exposure to COVID-19 can result in severe illness, intensive therapies, extended intubation and/or ventilator support, life-altering changes to my health, and even death.
RISK OF DISCLOSURE: The U.S. Centers for Disease Control and Prevention and the Los Angeles County Department of Public Health requires the Provider and the laboratory processing my specimen to report my test results, whether positive or negative, to my local public health authority. In addition to the test results, Praesidium will report certain personal information, not limited to, my age, sex, ethnicity, and zip code. You understand that although Praesidium implements a wide range of administrative, physical, and technical safeguards to protect health information and comply with HIPAA, it cannot guarantee the privacy and confidentiality of all health information. For more details, please review our Notice of Privacy Practices.
SEEK OTHER SOURCES OF CARE FOR OTHER HEALTH NEEDS: Please note that Praesidium does not take direct responsibility for your health or care beyond facilitating needed testing. Our services are limited to COVID-19 testing. The physicians who order tests are not your doctors for any other purposes. You need to seek other sources of care for your healthcare needs, including to examine any other health issues you may experience and to treat you for COVID-19 or any other conditions you have.
TESTING LIMITATIONS: I understand the Test is available as a result of the FDA’s Emergency Use Authorization (“EUA”) under Section 564 of the Federal Food, Drug, and Cosmetic Act. The EUA’s make available diagnostic tests to diagnose and respond to public health emergencies by allowing unapproved medical products or unapproved uses of approved medical products to be used in an emergency to diagnose, treat, or prevent serious or life-threatening diseases or conditions caused by chemical, biological, radiological and nuclear threat agents when there are no adequate, approved, and available alternatives. As a result, Testing may be subject to certain limitations as set forth in this Informed Consent.
NOT FOR EMERGENCIES: Praesidium does not provide healthcare on an emergency basis anywhere at any time and is not a substitute for your physician. Please do not delay seeking care from in a medical emergency or in place of your doctor. In an emergency, dial 911 or go to a hospital emergency department.
RIGHT TO DECLINE CLIENT: Please understand that Praesidium reserves right to refuse to provide collection kits, if, in Praesidium’s judgment, you are not a good candidate for our services.
AGREEMENT TO ANSWER THE ONLINE QUESTIONAIRE TRUTHFULLY AND USE SERVICES HONESTLY: You accept the responsibility to provide full and truthful answers to all questions and, when requested, to provide all other data in the most accurate form possible.
If you do not understand anything in this Consent, do not proceed. If you go forward with the COVID-19 testing, we will assume that you understood and were able to discuss your questions and concerns to your satisfaction.
COVID-19 INFORMED CONSENT: By clicking that I have read and agree to this informed consent, I hereby acknowledge that I have been advised of the above risks, benefits, and alternatives identified below with respect to COVID-19 testing and the current pandemic-related changes to treatment and care. I have had the opportunity to discuss the risks identified below, to questions, and receive answers to my satisfaction. By signing below, I hereby authorize and direct the provider to administer COVID-19 testing.
I hereby hold harmless, release, and forever discharge Praesidium’s and all health professionals involved in my testing from all claims, demands, and causes of action that I, my heirs, representatives, executors, administrators, or any other persons acting on my behalf or on behalf of my estate have or may have by reason of any problems associated with COVID-19 testing.
Data Sharing: When booking a test with a prepaid discount code created by your employer or supervisor you consent for the data to be shared with your employer including any medical results or other health information related to the delivery of service. If you do not consent for your results to be shared with your employer or supervisor yet still want to use the pre-booked test please reach out to support@sameday-testing.com.
INFORMED CONSENT FOR INTRAMUSCULAR INJECTIONS
CONSENT FOR CARE
You approve, authorize Praesidium Diagnostics dba Sameday Health and Jeff Toll MD, and any employee working under the direction of the physician, to provide medical care, or to this patient for which you are the legal guardian. This medical care may include services and supplies related to your health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment.
You understand during the course of the proposed treatment(s), test(s), or examination(s) unforeseen conditions may arise which may necessitate additional treatment(s), test(s), or examination(s). You consent to the performance of additional treatment(s), test(s), or examination(s).
It is important that you read this information carefully and completely. Please read and acknowledge this form before receiving your injection today. Parental consent is required for minors. If someone is translating for you, they must read you the form and you must approve.
You have the right to be informed about potential risks, complications, and possible benefits involved so that you may make the decision whether or not to undergo the procedure. This Informed Consent Form is not meant to scare or alarm you; it is simply an effort to make you better informed so that you may give or withhold consent for the procedure. Intramuscular (or IM) injection involves the injection of a substance directly into a muscle. IM injections are used for particular forms of nutrients and that are administered in small amounts (1-3cc). Depending on the compounds injected, they may be absorbed fairly quickly or more gradually. Our medical staff will administer the IM injection into the deltoid muscle (shoulder)
Proper diagnosis and treatment of a medical condition requires a formal office visit with a medical physician. Thrombocytopenia (low platelet counts) and coagulopathy (bleeding tendency) are contraindications for intramuscular injections, as they may lead to bruising and/or excessive bleeding. A routine blood test is recommended at least yearly to assess proper organ function. While no adverse reactions have been known to occur with any of the shot ingredients administered by this office, there are risks and hazards related to the performance of any injection. These risks include pain, erythema (redness), local edema (swelling), bleeding, bruising, injection fibrosis (scar tissue formation), headache, lightheadedness, and allergic reaction. Immediate medical attention may be necessary if you have a significant adverse reaction. Adverse reactions requiring immediate attention include, but are not limited to, fever of 101oF, chills, redness, drainage, or swelling at the injection site.
You understand that a record of my treatment will be generated with each visit. We are committed to your privacy and all health care information provided to Sameday Health and affiliated companies will be protected. Any disclosures of PHI (protected health information) will therefore require authorization unless used in the following ways:
Quality improvement regarding Sameday Health
Health-related benefits and services referral
Any court-ordered requests or subpoenas
Any law or government mandates with an appropriate warrant
You understand the information provided on this form and agree to all therein. You understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures set forth above have been adequately explained to me by my provider. You understand that you are free to withdraw my consent and discontinue participation in their treatments at any time.
You understand that, except in emergencies, you must give 24 hours notice of intent to cancel or reschedule my appointment. You understand that you will incur the full fee for treatment, regardless of the amount of supply used due to wasted materials.
INFORMED CONSENT TO DRAW BLOOD
CONSENT FOR CARE
You approve, authorize Praesidium Diagnostics dba Sameday Health and Jeff Toll MD, and any employee working under the direction of the physician, to provide medical care, or to this patient for which you are the legal guardian. This medical care may include services and supplies related to your health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment.
You understand during the course of the proposed treatment(s), test(s), or examination(s) unforeseen conditions may arise which may necessitate additional treatment(s), test(s), or examination(s). You consent to the performance of additional treatment(s), test(s), or examination(s).
CONSENT TO DRAW BLOOD
You hereby give permission for a representative of Praesidium Diagnostics dba Sameday Health and Jeff Toll MD to obtain a sample of my blood for tests, which you have asked to be performed on said sample. You understand that a confidential copy of the results of this testing will be sent to the offices of Praesidium Diagnostics dba Sameday Health, Jeff Toll MD and the associated laboratory, my employer (if applicable), and to me via my preferred method (below).
You understand your rights as a client in regards to HIPAA regulations; that information is confidential and shared with no one unless my permission is obtained; however, you are aware that during a venipuncture blood draw there’re always risks of bleeding, infection, and bruising.
You understand that a record of my treatment will be generated with each visit. We are committed to your privacy and all health care information provided to Sameday Health and affiliated companies will be protected. Any disclosures of PHI (protected health information) will therefore require authorization unless used in the following ways:
Quality improvement regarding Sameday Health
Health-related benefits and services referral
Any court-ordered requests or subpoenas
Any law or government mandates with an appropriate warrant
You understand the information provided on this form and agree to all therein. You understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures set forth above have been adequately explained to me by my provider. You understand that you are free to withdraw my consent and discontinue participation in their treatments at any time.
You understand that, except in emergencies, you must give 24 hours notice of intent to cancel or reschedule my appointment. You understand that you will incur the full fee for treatment, regardless of amount of supply used due to wasted materials.
INFORMED CONSENT FOR IV-THERAPY
CONSENT FOR CARE
You approve, authorize Praesidium Diagnostics dba Sameday Health and Jeff Toll MD, and any employee working under the direction of the physician, to provide medical care, or to this patient for which you are the legal guardian. This medical care may include services and supplies related to your health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment.
You understand during the course of the proposed treatment(s), test(s), or examination(s) unforeseen conditions may arise which may necessitate additional treatment(s), test(s), or examination(s). You consent to the performance of additional treatment(s), test(s), or examination(s).
CONSENT FOR IV-THERAPY
This document is intended to serve as confirmation of informed consent for IV therapy as ordered by Neudrip. You have informed the provider of any known allergies to drugs, supplements, or other substances that may be included in the ingredients of my solutions, or of any past reactions to anesthetics. In doing so, you understand that the sole risk of injury or harm that results from any participation in said therapy rests solely with you insofar as to the extent to which you do not disclose those allergies in advance.
You have informed the provider of all current medications and supplements. In doing so, you understand that the sole risk of injury or harm that results from any participation in said therapy rests solely with you in so far as to the extent to which you do not disclose my health conditions, medications, or supplements in advance.
You have informed the provider of all medical conditions, diseases, and illnesses. You attest that you have never been diagnosed with or treated for any such conditions that would put you at increased risk while receiving IV therapy services by Neudrip. You understand that you will be screened for said conditions prior to initiation of services.
You understand that you have the right to be informed of the risks and benefits before therapy administration. No procedures will be performed until you have had an opportunity to receive such information and to give you informed consent. Neudrip therapies are not intended for emergency care. The intravenous (IV) procedure involves inserting a needle into your vein and infusing the prescribed nutrients and/or medications over a determined period of time. That time will vary depending on your anatomy and infusion rate, however the therapy should be expected to take about 30 to 60 minutes.
You understand that IV therapy carries with it both risks and benefits. Some of those risks and benefits include, but are not limited to:
The Risks and potential side effects
Discomfort, soreness, bleeding, bruising, pain and possible scarring at the site of injection.
Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury.
Lightheadedness or fainting.
Severe reaction to medication, supplement or vitamin therapy; anaphylaxis, cardiac arrest or death.
Volume overload.
Air embolism.
Infiltration
The Benefits
Injectables are not affected by stomach or intestinal disease.
Total amount of infusion enters the bloodstream and is available to the tissues.
Higher doses of nutrients can be given by vein than by mouth,
Can be used in conjunction with oral supplementation and/or dietary and lifestyle changes.
You are aware that other unforeseeable complications could occur. You understand the risks and benefits of the procedure and have had the opportunity to have all of my questions answered. You understand that you have the right to consent to or refuse any proposed treatment at any time before or during its performance. You consenting to this form affirms that you have given my consent to IV therapy with any different or further procedure/medications, which in the opinion of my physician(s) or other(s) associated with this practice, may be indicated.
Lastly, you attest that you are not under the influence of illegal drugs or substances at the time of therapy. You agree that you am not using said therapy to recover from any drug related symptoms. You understand that if any suspicion of such is made by the provider, my right to therapy administration will be waived and will not be subject to a refund.
You understand that a record of my treatment will be generated with each visit. We are committed to your privacy and all health care information provided to Sameday Health and affiliated companies will be protected. Any disclosures of PHI (protected health information) will therefore require authorization unless used in the following ways:
Quality improvement regarding Sameday Health
Health-related benefits and services referral
Any court-ordered requests or subpoenas
Any law or government mandates with an appropriate warrant
You understand the information provided on this form and agree to all therein. You understand that there is no implied or stated guarantee of success or effectiveness of any treatment. The procedures set forth above have been adequately explained to me by my provider. You understand that you are free to withdraw my consent and discontinue participation in their treatments at any time.
You understand that, except in emergencies, you must give 24 hours notice of intent to cancel or reschedule my appointment. You understand that you will incur the full fee for treatment, regardless of amount of supply used due to wasted materials.
DO NOT DIGITALLY CONSENT TO THIS FORM UNLESS YOU HAVE READ IT AND UNDERSTAND IT. ASK ANY QUESTIONS YOU HAVE BEFORE ACKNOWLEDGING CONSENT.
Based on the above, I certify that I have read the foregoing Informed Consent, had opportunities to ask questions, agree and accept all of the terms above, and voluntarily consent as noted above.