HIPAA Notice of Compliance & Informed Consent

PLEASE READ THIS FORM CAREFULLY AND SIGN BELOW TO PROVIDE YOUR CONSENT.

I acknowledge and understand that by signing this consent form, I am voluntarily agreeing to undergo treatments at Eve Medical Center LLC., dba Med-Glow, located at 2630 Forest Hill Blvd, West Palm Beach, FL 33406.

  1. INFORMED CONSENT FOR TREATMENT: I acknowledge that I have discussed or will discuss with the provider(s) at Med-Glow the nature and purpose of the treatments I will be receiving. I understand that the results of these treatments may vary and that no guarantees can be made as to the outcome. I understand that there are risks and potential complications associated with any medical or cosmetic procedure. I agree to follow all pre- and post-treatment instructions provided by Med-Glow and acknowledge that my failure to do so may result in complications or reduced treatment efficacy.

  2. HIPAA NOTICE OF PRIVACY PRACTICES: I understand that Eve Medical Center LLC., dba Med-Glow, is required by law to maintain the privacy of my protected health information (PHI) and provide me with a notice of its legal duties and privacy practices. I acknowledge that I have received and reviewed a copy of Med-Glow's Notice of Privacy Practices, which explains how my PHI will be used and disclosed under the Health Insurance Portability and Accountability Act (HIPAA). I hereby give my consent for Eve Medical Center LLC., dba Med-Glow, to use and disclose my PHI for the purposes of treatment, payment, and health care operations as described in the Notice of Privacy Practices.

  3. FINANCIAL RESPONSIBILITY: I understand that I am financially responsible for all charges associated with my treatments at Eve Medical Center LLC., dba Med-Glow. I agree to pay all fees in full at the time of service or in accordance with any payment plans agreed upon by Med-Glow and me. I acknowledge that Med-Glow may charge a cancellation fee for missed appointments or appointments canceled with less than 24 hours' notice.

  4. ELECTIVE COSMETIC TREATMENTS: I acknowledge that any cosmetic procedures such as Botox, Derma Fillers, Lip Fillers, IV Infusion, CoolTone, CoolSculpting, Weight-loss Management Treatments, PRP, Morpheus8, and any other cosmetic treatments offered by Eve Medical Center LLC., dba Med-Glow are completely elective and chosen by me. I understand that these procedures are not medically necessary and that I am choosing to undergo them at my own discretion.

  5. MALPRACTICE INSURANCE NOTICE: I understand that Eve Medical Center LLC., dba Med-Glow, does not carry medical malpractice insurance. Florida law does not require healthcare providers to carry such insurance, and I have been informed of this fact. I accept the risk of not being able to recover damages in the event of injury, loss, or damage resulting from my treatments at Med-Glow.

  6. PHOTOGRAPHIC RELEASE: I consent to the taking of photographs, digital images, or videos of me or the treated areas by Med-Glow for the purpose of medical documentation, education, and marketing. I understand that my identity will be protected and that any images used for marketing purposes will not include personally identifiable information.

CONSENT AND AUTHORIZATION

I certify that I have read and fully understand this Patient Consent Form, and I have had the opportunity to ask questions and have them answered to my satisfaction. I voluntarily agree to receive treatments at Eve Medical Center LLC., dba Med-Glow, and I understand that I may revoke this consent in writing at any time.