PATIENT CONSENT FOR WEIGHT LOSS THERAPY WITH 660 IV Health If you are late or miss your appointment, you may be subject to a $50 fee. Services must be paid for at the time of service. Health insurance typically does not cover services provided at 660 IV Health. If you want to seek insurance reimbursement, we would be happy to provide you itemized invoices that you can submit to your insurance company. I understand that therapy used at 660 IV Health might not be considered a medical necessity. Therapy rendered are for the purpose of improving your quality of life through nutritional and supplemental counseling, and weight loss therapy. I agree that if I am having any side effects or become sick, that I will follow up with my primary care provider or go to an urgent care or emergency department. I acknowledge that 660 IV Health and Carolyn Kundert, PA are not my primary care provider unless I elect them so. I agree that I will continue with routine care through my primary care provider and notify them of therapies prescribed at 660 IV Health. I understand that there are no refunds for services or products rendered. We cannot accept back used medications once they have been dispensed per state regulation. I understand that having an appointment with 660 IV Health does not necessarily entitle me to being issued a prescription for weight loss medication or additional medications. Every individual is different, and it is at the medical providers discretion to issue a prescription. I understand that I must maintain my follow up appointments to remain on the program. It is important that lab work is monitored regularly every 6 months for safety purposes. It is important that Carolyn Kundert, PA manages my program and it is at their discretion to provide. I acknowledge that I have been advised of the risks and benefits of therapy. I also acknowledge that I have been advised of possible complications and side effects. I understand the risks, benefits, complications, and side effects of the program. I am voluntarily requesting therapy with 660 IV Health and Carolyn Kundert, PA in regards to weight loss therapy as determined by a mutual decision between myself and the medical provider. I agree that I will follow up with my primary care provider to obtain these screenings and I hold 660 IV Health harmless if an adverse event occurs during my program. I will ensure that my primary care provider provides the results of such screenings to 660 IV Health as this could change the therapy prescribed to me. I have read, understand, and agree to all the above statements. Print Name(Required) First Last Signature(Required)Date(Required) MM slash DD slash YYYY Better Health Care is Our Mission 24/7 service. Same Day Appointments are Available. (660)339-6006 email@example.com Book an Appointment Today!