Patient Consent for Treatment and For Use and Disclosure of Private Health Information 

I authorize medical treatment as deemed necessary and appropriate by the providers of bluedoor PC, and their employees participating in my care. 

With my consent, bluedoor PC, may use and disclose Protected Health Information (PHI), about me to carry out treatment, payment and healthcare operations. Please refer to the bluedoor PC’s Notice of Privacy Practices for a more complete description of such uses and disclosures. 

With my consent, bluedoor PC may call my home or other designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out treatment, payment or healthcare operations, such as appointment reminder, insurance items and any call pertaining to my clinical care, including laboratory results among others. 

With my consent, bluedoor PC may mail to my home or other designated location any items that assist the practice in carrying out treatment, payment or healthcare operations such as long as they are marked. 

With my consent, I authorize bluedoor PC to release medical information regarding the care and treatment I have received from this office to the providers I have listed on the reverse side of this form. 

With my consent, bluedoor PC may mail to my home or other designated location any items that assist the practice in carrying out treatment, payment or healthcare operations such as long as they are marked. 

With my consent, I authorize bluedoor PC to release medical information regarding the care and treatment I have received from this office to the providers I have listed on the reverse side of this form. 

I have the right to request that bluedoor PC restrict how it uses or discloses my PHI to carry out treatment, payment or healthcare operations. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

I authorize payment of insurance benefits directly to bluedoor PC. I understand that I am fully responsible for any medical or surgical charge incurred in the course of my treatment, co-pay, or deductible. 

I hereby authorize my provider to release pertinent information to my health insurance companies required in the course of my examination or treatment. 

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, bluedoor PC has the right to decline to provide treatment to me. 

By signing this form, I am consenting bluedoor PC’s use and disclosure of my personal health information to carry out treatment, payment and healthcare operations. 

Patient Consent for Contact 

You expressly consent and agree that, in order to discuss or service your accounts(s) (the “Accounts “) or to collect amounts you may owe, bluedoor PC, and its officers, agents, affiliates, employees, and any affiliated or associated service providers and any third-party debt collection agency associated therewith (collectively, “We”) may contact you by telephone at any telephone number associated with the Accounts, including wireless telephone numbers, which could result in charges to you. You expressly consent and agree that We may also contact you by sending text messages, emails, using any e-mail address you provide to us, or by pre-recorded or artificial voice or voice messages, automatic dialing methods, systems, or devices, and pre-recorded or artificial voice prompts at any telephone number associated with the Accounts, including wireless or mobile telephone numbers, regardless of whether you incur charges as a result. 

As part of your visit to bluedoor PC, you agree to receive electronic communications from us in the form of emails, text messages or automated phone calls, containing important information about your health . You verify that the contact information (email address, mobile phone number, landline number) provided by you belongs to you and is accurate. Further, the text messages and calls to your mobile phone will be delivered using an automated dialing system. These messages may include your name and health information and may not be encrypted. You may opt-out of these communications at any time by selecting the corresponding option in each message or by calling us at bluedoor PC. 

Service Agreements

The following service agreements only apply should you elect for the service to be performed during your visits with bluedoor. If you do not elect for any of the below services, then the information pertaining that service below does not apply.

1. X-Ray Examination:

1. Before undergoing X-Ray examination, I have been informed that radiation exposure may be harmful to my health and to the health of my fetus.
2. By means of this statement, I have been asked to notify the X-Ray technician if I am or believe I may be pregnant.
3. Before undergoing an X-Ray examination, I was asked to provide this information in case of pregnancy in order to assure appropriate measures can be taken for the protection of my fetus and myself. 
4. I am aware of and can recall when my last menstrual period started, and to the best of my knowledge, I am not pregnant.

2. Vitamin injection and IV:  

If I request vitamin therapy (injections and IV). The injection of vitamins offered have been explained to me and my questions regarding such treatment have been answered to my satisfaction. The information given to me has been in clear terms and I understand the risks, benefits, possible side effects and complications of the treatment.

1. I understand the recommended dose for B12 is 1 to 2ML intramuscular bi weekly. 
2. Possible side effects can include irritation at the site, infection, bruising, and tenderness at the injection site.
3. I certify that I do not have an allergy to sulfa or cobalt.
4. I certify that I do not have a liver or kidney impairment that I am aware of or any of the other contraindications listed.
5. I understand that additional maintenance dosing of B12/MIC will require current B12 baseline level be established through blood testing.  

Before this and EVERY injection I will inform bluedoor PC staff if I have any of the following: Lebers Disease, Kidney Disease, Liver Disease, Any infection, Iron deficiency, Talking methotrexate, Cobalt/Sulfa allergy, Polycythemia Vera (blood disorder), History of Gout, Fatigue, Low depressed mood, Pernicious Anemia, Weight issues, Irritability/moodiness, Pregnant/trying to become pregnant, Breast feeding, Heart Disease, Diabetes, Memory loss/Alzheimer’s, Sleep disorders, Osteoporosis, Tendonitonits, Asthma, Allergies, History of Migraines, Immunosuppression, Thyroid disorders, IBS/Inflammatory Bowels, Numbness/tingling of body, Leber’s Disease.

I certify that I am in good health and/or have my physician’s approval.  I have read the above information about the vitamin injection.  I have the opportunity to ask my personal physician’s questions that I may have had before receiving this injection.  I understand the benefits and risks regarding this injection.  I release bluedoor PC, their doctors, and employees, directors, from any and all liability arising from or in connection with this injection.  

Vitamins used are safe and non-toxic even when taken in high doses, however I understand that it is possible that I could have an adverse reaction, though rare they can include: mild diarrhea, anxiety/panic attacks, heart palpitations, insomnia, breathing problems, chest pain, skin rashes/hives. Most common side effects are redness/swelling and soreness around the injection site lasting up to a few days. We strongly recommend all of our clients have current blood work completed and/or and have regular check-ups with a Primary Care Provider. If at any time you are faced with a medical emergency, please contact your nearest Emergency Department or dial 911. Vitamins and nutritional supplements are not intended to diagnose, treat, cure, or prevent any diseases or illnesses.

3. TELEMEDICINE:

Telemedicine involves the use of electronic communications to enable health care providers at different locations to share individual patient medical information for the purpose of improving patient care. Providers may include primary care practitioners, specialists, and/or subspecialists. The information may be used for diagnosis, therapy, follow‐up and/or education, and may include any of the following:

• Patient medical records
• Medical images
• Live two‐way audio and video
• Output data from medical devices and sound and video files

Electronic systems used will incorporate network and software security protocols to protect the confidentiality of patient identification and imaging data and will include measures to safeguard the data and to ensure its integrity against intentional or unintentional corruption.

EXPECTED BENEFITS

• Improved access to medical care by enabling a patient to remain in his/her office (or at a remote site) while the physician obtains test results and consults from healthcare practitioners at distant/other sites.
• More efficient medical evaluation and management.
• Obtaining expertise of a distant specialist.

POSSIBLE RISKS

As with any medical procedure, there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to:

• In rare cases, information transmitted may not be sufficient (e.g. poor resolution of images) to allow for appropriate medical decision making by the physician and consultant(s);
• Delays in medical evaluation and treatment could occur due to deficiencies or failures of the equipment;
• In very rare instances, security protocols could fail, causing a breach of privacy of personal medical
• information;
• In rare cases, a lack of access to complete medical records may result in adverse drug interactions or
• allergic reaction or other judgment error;
• Please initial after reading this page:

BY SIGNING THIS FORM, I ATTEST TO AND UNDERSTAND THE FOLLOWING:

1. I understand that the laws that protect privacy and the confidentiality of medical information also apply to telemedicine, and that no information obtained in the use of telemedicine which identifies me will be disclosed to researchers or other entities without my consent,

2. I understand that I have the right to withhold or withdraw my consent to the use of telemedicine in the course of my care at any time, without affecting my right to future care or treatment,

3. I understand that I have the right to inspect all information obtained and recorded in the course of telemedicine interaction, and may receive copies of this information for a reasonable fee,

4. I understand that a variety of alternative methods of medical care may be available to me, and that I may choose one or more of these at any time. The staff at Venice Culver Marina Urgent Care by bluedoor has explained the alternatives to my satisfaction,

5. I understand that telemedicine may involve electronic communication of my personal medical information to other medical practitioners who may be located in other areas, including out of state.

6. I understand that it is my duty to inform the staff at Venice Culver Marina Urgent Care by bluedoor of electronic interactions regarding my care that I may have with other healthcare providers.

7. I understand that I may expect the anticipated benefits from the use of telemedicine in my care, but that no results can be guaranteed or assured.

8. I attest that I am located in the state of California and will be present in the state of California during all telehealth encounters with the staff at Venice Culver Marina Urgent Care by bluedoor.

PATIENT CONSENT TO THE USE OF TELEMEDICINE

I have read and understand the information provided above regarding telemedicine, have discussed it with my physician or such assistants as may be designated, and all of my questions have been answered to my satisfaction. I hereby give my informed consent for the use of telemedicine in my medical care.

I hereby authorize the staff at Venice Culver Marina Urgent Care by bluedoor to use telemedicine in the course of my diagnosis and treatment.

4. COVID - 19 Testing Consent

I authorize a) mid-turbinate nasal swab for COVID-19 Test, b) lateral flow immunofluorescent sandwich assay intended for the qualitative detection of the nucleocapsid protein antigen from SARS-CoV-2 in nasopharyngeal (NP) and nasal (NS) swab specimens, c) a rapid serology test for the qualitative detection of SARS-CoV-2 IgG and IgM antibodies in venous whole blood, serum and plasma for myself. I understand, agree, certify, and authorize the following: 

1. The patient named above is of legal consenting age. Or, I am the parent or legal guardian of consenting age (if the patient is a minor or dependent) of the patient named in the attached application.
2. I authorize bluedoor Urgent Care to collect the specimen. 
3. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. 
4. I acknowledge that a positive test result is an indication that I must self-isolate and/or wear a mask or face covering as directed in an effort to avoid infecting others. 
5. I understand the testing unit is not acting as my medical provider, this testing does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens.
6. I understand that, as with any medical test, there is the potential for a false positive or false negative COVID-19 test result. 
7. bluedoor Urgent Care has contracted with Primex Laboratories and Flowhealth Laboratories for laboratory analysis of my mid-turbinate nasal swab and report of my specimen. I authorize Primex and Flowhealth to perform testing on my specimen. 
8. Rapid serology test for the qualitative detection of SARS-CoV-2 IgG and IgM antibodies in venous whole blood, serum and plasma is furnished by Healgen Scientific. I authorize bluedoor to interpret results of the test. 
9. I understand that if I do not provide the name and fax number of a physician or healthcare provider, it is my responsibility to contact my physician or authorized healthcare provider of the results and discuss the results with my healthcare provider.  
10. I understand that if I am currently experiencing symptoms related to COVID 19, I should contact my healthcare provider. 
11. I authorize all results to be release to the following email indicated in my registration. I also authorize results to be communicated through text message to the mobile phone number I provided.

I, the undersigned, have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed Consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask additional questions at any time. I voluntarily agree to this testing for COVID-19.

Acknowledgement of Receipt of Privacy Practices 

By signing/e-signing this document, I acknowledge that I have been offered a copy of the Notice of Privacy Practices for the Practice of bluedoor PC.