Well GI Center
Patient Consent for Use and Disclosure of Protected Health Information
Patient Acknowledgment of Understanding of Naturopathic Medicine
Patient Waiver and Hold Harmless Agreement
I hereby give my consent for Well GI Center to use and disclose protected health information (PHI) about me to carry out wellness treatment, payment and health care operations (TPO). (The Notice of Privacy Practices provided by Well GI Center describes such uses and disclosures more completely.)
I have the right to review the Notice of Privacy Practices prior to signing this consent. Well GI Center reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Well GI Center 10911 Bonita Beach Road #1021 Bonita Springs, Florida 34134.
With this consent, Well GI Center may call my home or other alternative location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any calls pertaining to my clinical care, including laboratory test results, among others.
With this consent, Well GI Center may mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked “Personal and Confidential.”
With this consent, Well GI Center may e-mail to my home or other alternative location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Well GI Center restrict how it uses or discloses my PHI to carry out TPO. The practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.
By digitally signing this form, I am consenting to allow Well GI Center to use and disclose my PHI to carry out TPO.
I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, or later revoke it, Well GI Center may decline to provide treatment to me.
The Naturopathic practitioners of Well GI Center are trained specialists who use non-invasive Naturopathic modalities to create a healthy environment of mind, body, and spirit.
I authorize Well GI Center to perform services to develop a natural, complementary health and wellness improvement program for me in order to assist me in improving my overall health and not for the treatment or "cure" of any disease.
I understand that Naturopathic Doctors are not licensed or regulated in the state of Florida. Well GI Center and its practitioners will not diagnose or treat any diseases and/or disorders.
I understand that the services/modalities rendered are safe, non-invasive Naturopathic modalities/methods of balancing the body's physical, emotional, and nutritional needs and those imbalances can cause, or contribute to, various health problems.
I understand that I should continue to see any medical doctors I am currently under the care of, and that any prescription medication(s) should not be altered without first consulting the Doctor who recommended it.
Nothing said, done, typed, printed, or reproduced by Well GI Center is intended to diagnose, prescribe, treat, or take the place of a licensed medical doctor.
By booking, purchasing, or attending an appointment for any service at Well GI Center I hereby release, waive, discharge, and covenant not to sue Well GI Center from any and all liability, claims, demands, actions, and cause of action whatsoever arising out of, or related to, any loss, damage, or injury, including death, that may be sustained by me, or to any property belonging to me, while participating in such activity, while in, on, or upon the premises where the activities are being conducted, regardless of whether such loss is caused by the negligence of the releases, or otherwise and regardless of whether such liability arises in tort, contract, strict liability, or otherwise, the the fullest extent allowed by law.
I acknowledge that I am fully aware of the risks and hazards connected with the activities of Naturopathic modalities and practices/methods and I am aware that such activities include the risk of injury and even death, and I hereby elect to voluntarily participate in said activities, knowing that the activities may be hazardous to my body and my property.
I understand that Well GI Center does not require me to participate in these activities. I voluntarily assume full responsibility for any risks of loss, property damage, or personal injury, including death, that may be sustained by me, or any loss or damage to property owned by me, as a result of being engaged in such activities, whether caused by the negligence of releases or otherwise, to the fullest extent aloowed by law. I further hereby agree to indemnify and hold harmless the releases from any loss, liability, damage, or costs, including court costs, and attorney's fees that Releasees may incur due to my participation in said activities, whether caused by the negligence of releases or otherwise, to the fullest extent allowed by law.
It is my express intent that this Waiver and Hold Harmless Agreement shall bind the members of my family and spouse, if I am alive, and my heirs, assignees and personal representative(s), if I am deceased, and shall be deemed as a release, waiver, discharge, and covenant not to sue the above-named Releasees.
I hereby further agree that this Waiver of Liability and Hold Harmless Agreement shall be constructed in accordance with the laws of the state of Florida and that any mediation, suit, or other proceeding must be filed or entered into only in Florida and the Federal or State courts of Florida. Any portion of this document deemed unlawful or unenforceable is severable and shall be stricken without any effect on the enforceability of the remaining provisions.
In digitally signing this document, I acknowledge and represent that I have read and understand the foregoing Patient Consent for Use and Disclosure of Protected Health Information, Patient Acknowledgment of Understanding of Naturopathic Medicine, and Patient Waiver and Hold Harmless Agreement and that I am signing it voluntarily as my own free act and deed; no oral representations, statements, or inducements, apart from the foregoing written agreement, have been made; I am at least eighteen (18) years of age and fully competent; and I execute this/these Agreement(s) for full, adequate and complete consideration fully intending to be bound by the same.
I hereby acknowledge that by purchasing and/or booking an appointment through Well GI Center's website at wellgi.com I am digitally signing this document and acknowledge agreement and full understanding of the above statement(s).
NOTE: There is a $25 non-refundable administration fee for all no-shows or cancellations within 24 hours of the scheduled appointment. Before 24 hours appointments may be rescheduled without penalty.