Cardiatrics Corporation ("practice") provides a preventive cardiovascular disease program ("program") to its clients. The program includes a clinical assessment of your risk of heart disease, lifestyle/behavioral interventions, lifestyle coaching, social gatherings, clinically measuring the effectiveness of the Service, other lifestyle related guidance with the supervision of a physician or specialist, and offerings outlined on the Site. Any service outside the scope of the aforementioned list is not in the purview of the Company’s list of Services and is subject to additional charges. The clinical results/effectiveness of the Service such as coaching and lifestyle interventions may vary from person to person due to a variety of reasons such as:
I hereby voluntarily request and consent to be a part of the preventive heart disease program through Cardiatrics Corporation.
I understand that Cardiatrics Corporation and any person associated with the program does not diagnose any medical condition, treat illnesses or prescribe medicine or drugs. I understand that this program is not a substitute for adequate medical care, diagnosis and/or treatment from a medical doctor. If I experience any cardiac discomfort, pain or suffering, I understand that it is my responsibility to immediately see/contact a licensed physician or seek emergency assistance and under no circumstances should I forego any medical treatment recommended by a doctor.
I understand that my participation in the program is based on the analysis of my blood test results and the overall assessment of my condition from a doctor and their recommendation. Should my condition change in any way during the course of the program, Cardiatrics Corporation may determine, at their sole discretion, that I no longer meet the eligibility requirements to participate in the program and I will be notified accordingly.
I have provided all necessary medical, mental and physical information that is known to me at the time of accepting this document. I understand it is my responsibility to update the office and the doctor accordingly, in writing, of any changes to my medical, mental and/or physical condition. Should I not provide accurate information or fail to update the office and the doctor of any changes in writing, I agree to release Cardiatrics Corporation, the office, it’s predecessors, parent, subsidiaries and affiliates, officers, and employees of any and all liability for any and all injuries, damages or claims.
I have provided the office with a full and accurate list of all medications that I am currently taking. I understand that it is my responsibility to immediately tell the office and the doctor if I change or add to my current medications, so that proper precautions can be taken.
I understand that Cardiatrics will keep all communications and records confidential, unless I consent in writing to share this information with others. However, I consent to the Practice’s use and disclosure of my Protected Health Information (PHI) for the purpose of being a part of this program, for the purposes relating to the payment of services rendered to me and for the office’s general healthcare operations purposes. PHI relates to any information created or received by the office, that relate to my past, present or future physical and mental health or condition, that either identifies me or where there is a reasonable basis to believe the information can be used to identify me.
I acknowledge that I have read and understand the HIPAA privacy agreement provided to me by the Practice.
While there have been no warranties, assurances, or guarantees made to me, I consent and freely agree to be a part of the preventive cardiovascular disease program through Cardiatrics. I understand that while it or any of its associates may make certain recommendations to me during the program, it is entirely my own decision whether or not to accept and follow these recommendations. I have read and understood the information provided in this Consent Form, as well as all materials provided to me. I have asked any and all questions that I may have about the program and these questions have been answered to my full satisfaction.
I further agree to hold Cardiatrics Corporation, their office and any of their associates or staff harmless from any and all liabilities and claims, which may arise as a result of my participation in the program. I will not hold them responsible for the consequences of any decisions I may make, or any actions I may take, or may choose not to take, following any recommendations made by them.
I represent that I am of sound mind and am legally competent to understand and complete this agreement. I hereby execute this consent form without coercion.