Privacy and Consent


Created Date

We are extremely pleased that you have chosen our medical facility for your physical medicine treatments. Our providers and staf will work very diligently to make sure that you get the best results by making sure your visits are as efcient, efective, and comfortable as possible. Our medical facility provides an open, engaging atmosphere which enables patients to interact with one another during their visits. All examinations, re-examinations, consultations, and test results, will be discussed in the privacy of an examination room. If there is ever a time you would like to discuss any issues in private, just let any staf member know and we will gladly accomodate.

Thank you for your confidence in us. We look forward to serving you and your needs. Please sign below that you have read and fully understand the Patient Privacy Policy.

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy.

A Notice of Privacy Practices is be available to you in the office. The notice provides information about how we may use and disclose protected health information about you in order to carry out treatment, payment, and healthcare operations, and for other purposes permitted or required by law. The notice also contains information about your rights under the law.

By signing below you understand and agree to the terms of our notice of privacy practices which include:

Protected health information may be disclosed or used for treatment, payment, or health care operations.Authorization is required for certain disclosure of your Protected Health Information.You have the right to opt out of fundraising communications.You have the right to restrict disclosures of your Protected Health Information under certain circumstances.You have the right to be notified of a breach of unsecured Protected Health Information.

By signing below you understand and agree that:

The practice has a Notice of Privacy Practices that you have had the opportunity to review.The practice reserves the right to change the Notice of Privacy Practices and if we change our notice you may obtain a revised copy by contacting our office.You may revoke this consent in writing at any time and all future disclosures will cease.The practice may condition treatment upon the execution of this consent.

Informed Consent to Care

A patient coming to the medical provider gives his/her permission and authority to care for them in accordance with appropriate tests, diagnosis, and analysis. The clinical procedures performed are usually beneficial and seldom cause any problem. In rare cases, underlying physical defects, deformities, or pathologies may render the patient susceptible for injury. The medical provider, of course, will not provide specific health care if he/she is aware that such care may be contraindicated. It is the responsibility of the patient to make it known or to learn, through health care procedures, whatever he/she is sufering from: latent pathological defects, illnesses, or deformities, which would otherwise not come to the attention of the medical provider.

I agree to settle any claim or dispute I may have against or with any of these persons or entities, whether related to the prescribed care or otherwise, which will be resolved by binding arbitration under the current malpractice terms which can be obtained by written request.

I hereby give my consent to the Peak Vitality staf for assessments, examinations, techniques and treatments which may be recommended by Peak Vitality.

It is recommended that I contact my personal physician for any ailments that I may be experiencing. I acknowledge that no assurance or guarantee has been provided to me as to the results of the treatment. I acknowledge that with any treatment there can be risks and those risks have been explained to me and I assume those risks.

I acknowledge and understand that the Peak Vitality staf must be fully aware of my existing medical conditions. I have completed my medical history form as provided and disclosed all of those medical conditions afecting me. It is my responsibility to keep Peak Vitality updated on my medical history. The information I have provided is true and complete to the best of my knowledge.

I have fully read the this consent form and I have had the opportunity to question the contents and my therapy. By signing this form, I confirm my consent to treatment and intend this consent to cover the treatment discussed with me and such additional treatment as proposed by the Peak Vitality staf from time to time, to deal with my physical condition and for which I have sought treatment. I understand that at any time I may withdraw my consent and treatment will be stopped.

Peak Vitality Injection Procedure Consent

We are an integrated ofce that ofers a variety of injections to assist in relieving pain and enhance the efectiveness of several treatment types.

We use Marcaine, Lidocaine, Procaine (numbing agents) and/or Homeopathic and Herbal, Umbilical Cord Tissue, Bone Marrow Aspirate, Ozone Therapy (O3) and Platelet Rich Plasma(PRP) injections to decrease pain and inflammation, improve circulation and assist in healing. Umbilical Cord Tissue and PRP is also used in our ofce for sexual health and antiaging treatments. Dextrose, vitamin, amino acids and mineral injectables are potentially utilized in our injection therapies as well. We will not utilize steroids unless we are not getting a response from our more natural alternatives. Should you not respond to treatment and you choose to use a steroid, the lowest dose will be utilized and you will be informed prior to the use of any steroids.

We will not use steroids as an addition in any of our injections.

The incidence of serious complications, from the medications and substances listed above, is very low (less than 1% in our experience). Your provider believes the benefits of the procedure outweigh its risks or it would not have been ofered to you. It is your decision and right to accept or decline to have the procedure done

As with any medical procedure, there are some risks for complications that are relatively uncommon and include but are not limited to: bleeding, infection, allergic reaction to the injectables, and pain/swelling at injection site.

There is a remote risk of pneumothroax (lung collapse) with some injecitons. Signs of this would include chest pain, shortness of breath, and cough. Should these symptoms develop, you should report immediately to the emergency department for evaluation.

Having read this form, checks in the boxes below and my signature at the bottom acknowledges that: I voluntarily give my authorization and consent to the performance of the procedure(s) described below by my physician and/or his/her associates and that risks/ benefits have been discussed and that I have had the opportunity to ask questions.

Results Not Guaranteed - cannot be any guarantee or warranty, expressed or implied, that I will be completely satisfied by the outcome or that I will not require additional treatment and/or ongoing treatment to achieve the result I seek.

Acupoint Injections

Acupoint Injections are a specific type of injection that your physician can use for various symptoms and problems utilizing specific points along the acupuncture meridians. These treatments can consist of pharmaceutical grade herbs, vitamins, minerals, enzymes, and Sarapin. These injections may be used along or in conjunction with your regular treatment.

Hyaluronic Acid Injections (Polycyte)

Polycyte is derived from the extracellular matrix of the umbilical cord tissue layer of Wharton's Jelly. Polycyte contains a high concentration of Hyaluronic Acid (HA) and growth factors. HA Therapy can help relieve pain, improve mobility, and get you back to your normal activities. HA is a natural substance found in joint cartilage and in the fluid that fills the joints, synovial fluid. HA acts like a lubricant and shock absorber in synovial fluid of healthy joint.

Platelet Rich Plasma (PRP)

PRP injections assist with the treatment of musculoskeletal, rejuvenation and sexual health conditions using autologous (own blood) derived platelet rich plasma. For PRP, the injectable solution consists of your own plasma rich platelets, growth factors and sterile saline. There are no chemical added to the solution.

Trigger (Ashi) Point Injections

Trigger (Ashi) Point Injections are a specific type of local injection that your clinician can use to treat local areas of muscle pain and spasm. Trigger point injections can help break the cycle of pain in your back, neck and limbs to help restore normal function and motion.

Knee Injections

Knee Injections can be utilized to relieve pain and decrease inflammation to the knee joint.

Shoulder Injections

Injections in the shoulder joint are necessary for therapeutic reasons in the course of treatment for shoulder pain.

Hip and Back Joint Injections

If these joints experience arthiritis, injury or mechanical stress, one may experience hip, buttock, leg or low back , upper back or neck pain. A hip or back joint injections should be considered for patients with these symptoms. The injection can help relieve the pain, and decreases inflammation and improve range of motion.

Vitamin, Mineral and Amino Acid Injections

The benefits of these injectable are that they are not afected 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 or intramuscularly than by mouth without intestinal irritation that can accompany doses given by mouth.

Blood Thinner Consent

By checking here, I understand that if I am on a BLOOD THINNER (Aspirin, Plavix, Coumadin, Pradaxa, Arixtra), there is a slightly increased risk of bleeding at injection site and into the joint space for joint injections.

I have read or have had the above information read to me and by signing below I understand there are risks involved with the above mentioned procedures, that include rare complications, which may not have been specifically mentioned in the above information. The risks have been explained to my satisfaction and I accept them and consent to any procedures the providers prescribe to treat my condition.

This consent shall be valid for the duration of one (1) year or until specifically revoked.

I acknowledge that I have reviewed the Notice of Privacy Practices of this medical facility.

Please select one of the following options and sign below:

I wish to receive a paper copy of the Privacy Notice.

I wish to receive an electronic copy of the Privacy Notice.

NOTE: If you have requested either of the above please inform the front desk at the completion of this documentation.

I do not request a copy of the Privacy Notice at this time. I acknowledge that I can request a copy at any time and am aware that the Privacy Notice is available at the office.

I acknowledge that it is the policy of this medical facility to leave reminder messages on my answering machine or with another person in my home. I may make a request for an alternative means of communication (within reason) in writing.

I acknowledge that if I should have a problem or question in regard to my rights, I may speak with the Privacy Officer about my concerns.


I understand and agree that (regardless of whatever health insurance or medical benefits I have), I am ultimately responsible to pay the medical facility as well as all employees, employers, representatives, and agents thereof, (hereinafter collectively referred to as “Healthcare Provider”) the balance due on my account for any professional services rendered and for any supplies, tests, or medications provided.

I hereby authorize payment of, and assign my rights to, any health insurance or medical plan benefits directly to Healthcare Provider for any and all medical/healthcare services, supplies, tests, and/or medications that have been or will be rendered or provided; as well as designating and appointing Healthcare Provider as my beneficiary under all health insurance or medical plans which I may have benefits under.

I hereby authorize the release of any health status, conditions, symptoms or treatment information contained in your records that is needed to file and process insurance or medical plan claims, to pursue appeals on any denied or partially paid claims, for legal pursuit as to any unpaid or partially paid claims, or to pursue any other remedies necessary in connection with same.

I hereby assign directly to Healthcare Provider all rights to payment, benefits, and all other legal rights under, or pursuant to, any health plan (including, but not limited to, any ERISA plan, PPACA plan, or insurance contract) rights that I (or my child, spouse, or dependent) may have under my/our applicable health plan(s) or health insurance policy(ies). I also hereby appoint and designate that Healthcare Provider can act on my/ our behalf, as my/our representative, ERISA representative, or PPACA representative as to any claim determination, to request any relevant claim or plan information from the applicable health plan or insurer, to file and pursue appeals to obtain benefits and/or payments that are due to either Healthcare Provider, myself, and/or my family members as a result of services rendered by Healthcare Provider, and to pursue any and all remedies to which I/we may be entitled, including the use of legal action against the health plan or insurer. I hereby also declare that Healthcare Provider is my/our beneficiary regarding my/our health plan as contemplated by ERISA and PPACA, and that Healthcare Provider can pursue any and all rights that I/we may have under state and/or federal law regarding my/ our health plan. This assignment and/or designation will remain in efect unless revoked in writing. A photocopy or scan or this document is to be considered as valid and as enforceable as the original.

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended neurophysiological testing to be performed so that you may make an informed decision as to whether or not to undergo the testing after knowing the minimal risks and hazards involved. This disclosure is not meant to alarm you; it is simply an efort to make you more knowledgeable in order to decide whether to give or withhold you consent to the recommended procedure(s).

I acknowledge that I have been advised by my health care provider that I require further diagnostic testing in order to determine the status of my condition. I am also aware of my right to seek such diagnostic service by any provider of my choice who ofers such services.

I (we) understand that no warranty or guarantee has been made to me as a precise result or cure.

Just as there may be risks and hazards in continuing my present symptoms and condition without proper diagnosis and treatment, there are also risks and hazards related to the performance of any medical procedure(s) test planned for me. I (we) also realize that the following risks and hazards may occur in connection with this particular testing: Bleeding (minimal) and Infection (minimal). I (we) have been given an opportunity to ask questions about my condition, alternative forms of treatment, risks of not testing, the risks and hazards involved in the event of testing, and I (we) believe that I (we) have sufcient information to give this informed consent.

I (we) certify this form has been fully explained to me (us), that I (we) have read it or have had it read to me (us), that the blank spaces have been filled in, and that I (we) understand its contents. By signing this document, I am acknowledging my choice to receive this exam.

Patient's Signature:
Date: Form Created Date
Signature of Guardian if Applicable:
Date: Form Created Date