CONSENT TO DIAGNOSIS AND TREATMENT

  1. Emergency: If this is an emergency, I will dial 9-1-1 on my telephone. Affordable Mobile Doctor does not provide emergency medical care.  I understand that I am responsible for all costs associated with emergency care.
  2. Communication:  I agree to call +1 (480) 357-6275 and talk to a live person if I need to contact AMD for any reason.  I understand that AMD will call me back within twenty-four (24) business hours if they are not able to answer the phone. I will call from a different number if spam blocking is not allowing my phone number to go through to the receptionist.   I understand that I should not expect a response from emails, text messages, faxes, voicemails or mail, including but not limited to USPS, UPS, FedEx, etcetera. I understand texting is available as a courtesy but will follow up if I do not receive a response.  I agree to keep AMD up-to-date with my contact information including changes in any of the following areas:  name, allergies especially anaphylactic allergies, pharmacy phone number and address, emergency contact name and phone number, personal phone number, and mailing address.
  3. Payment: I understand that payment must be made in full prior to the doctor’s visit.  I understand that payment is for one medical concern during a five (5) minute consultation by a licensed physician.  Multiple concerns require multiple doctor visits.  Payment arrangements are not available.   Payment for a consultation may not result in the requested prescription, and the doctor has the right to not prescribe requested medications if the medication is not indicated or may cause harm.  Furthermore, there are conditions the doctor does not treat, and there are drugs the doctor does not prescribe.  I understand that payments are NEVER, under any circumstance, refunded. I understand that Affordable Mobile Doctor does not bill insurance nor does medical billing or coding for insurance purposes.  I understand that if have Medicare or Medicaid I do not qualify for services provided by Affordable Mobile Doctor. I understand that courier services are available and I will pay for courier services prior to a request for said services should the need arise. 
  4. Interpretation of Results: Results for labs and imaging require a follow-up visit for interpretation.  Each doctor visit is limited to one medical concern, therefore, the follow-up visit for the interpretation of results is limited to that task.  I will make an additional appointment if I have additional medical concerns.  Laboratory services provided by Professional Co-op can not be refunded. Under some special circumstances, I may have credit to use as I like for services provided (doctor visits, procedures, Professional Co-op services).
  5. Fees for Ancillary Services: As a patient of Affordable Mobile Doctor, I understand that doctor dispenses no medicine, and all prescriptions, including pharmaceuticals, herbs, vitamins and nutrients, are an additional cost to the doctor visit. I understand that I am financially responsible for all fees associated with the cost of care for ancillary services such as labs (with exception of Professional Co-op services) and imaging. These fees are to be paid directly to the provider (e.g.Fry’s Pharmacy, Bashas’ Pharmacy, SimonMed Imaging, LabCorp, Westcoast School of Ultrasound etc.)
  6. Emails: Because emails are not confidential, Affordable Mobile Doctor cannot discuss my medical information, nor give me a consultation by email.  I will not email Affordable Mobile Doctor any information regarding my health nor my medical concerns for which I have confidentiality concerns.  I will not email Affordable Mobile Doctor any financial information such as my credit card number or bank information.  I understand that Affordable Mobile Doctor will never ask me for health information nor financial information via email.  If I am ever asked for this type of information via email, I will disregard the email and notify Affordable Mobile Doctor immediately.  Many general questions are answered on the Affordable Mobile Doctor website at www.AffordableMobileDoctor.com.  Specific questions or comments for the doctor can be addressed by calling Affordable Mobile Doctor at +1 (480) 357-6275.
  7. Voicemails: I understand that Affordable Family Clinic needs to speak directly to me and will not violate HIPAA by emailing, texting, faxing, or leaving voicemails containing protected health information.  I will call +1 (480) 357-6275 until I speak to a person if I have any issues, concerns, comments, or needs.
  8. No Mutual Exclusivity: I understand that any treatment or recommendations provided to me as a patient of Affordable Mobile Doctor is not mutually exclusive from any other treatment or advice that I may be receiving now or in the future, from another healthcare provider.   I am at liberty to seek or continue medical care from a physician, surgeon, or another healthcare provider.
  9. Treatment Variance:  I understand that Affordable Mobile Doctor offers integrative family medical care.  For instance, if an antibiotic is indicated and prescribed, the doctor will most likely recommend probiotics.  Allopathic, Naturopathic, Homeopathic, or Chinese medical therapies provided by Affordable Mobile Doctor may be different from those usually offered by another licensed healthcare provider.  Not all therapies are FDA-approved.  I will ask the doctor during my consultation for more details if I am concerned about my specific treatment plan.
  10. Aggravation of Symptoms: I understand that Allopathic, Naturopathic, Homeopathic, or Chinese medical treatments can lead to a temporary aggravation of symptoms. Should I experience any symptoms which I associate with any part of my prescribed treatment, including, but not limited to, procedures, alternatives, risks, I understand that I should promptly call 9-1-1 if it is an emergency.  In the event that it is not an emergency, I will call Affordable Mobile Doctor at +1 (480) 357-6275 and continue calling until I speak to a live person.
  11. Side Effects: I understand that any treatment (including but not limited to Prescriptions of drugs (legend and over-the-counter drugs, herbs, vitamins, minerals, etcetera), Acupuncture, Intravenous Nutrient Therapy, and Manipulation) intended to help may have side effects.  While the chances of experiencing complications are small, it is the practice of Affordable Mobile Doctor to inform patients about them.   These complications may include, but are not limited to, soreness, temporary pain or discomfort, inflammation, soft tissue injury or bruising, dizziness, and temporary worsening of symptoms. More serious complications are extremely rare.  I understand that additional information on side effects and complications is available upon request. I understand it is my responsibility to seek medical attention IMMEDIATELY (for example, call 9-1-1) if I think I am having a serious or life-threatening reaction, and I agree to follow up with the doctor as soon as possible. It is also clinic policy to inform me of the procedure being performed and the risks and alternative treatments available.  If my physician does not explain to my satisfaction, I will ask for more information, and I will ask any questions I have. 
  12. Expiration Dates:  I understand that I must consent to treatment and diagnosis and have had a consultation with the doctor in the past six (6) calendar months in order to be an established patient.  I understand that I must be an established patient in order for the doctor to diagnose or treat me.  I understand that all orders, including but not limited to, recommendations, treatments, procedures, prescriptions, laboratory services, imaging, etcetera expire six (6) months from the last date of service.  I understand it is my responsibility to follow the doctor’s orders and recommendations in a timely manner.  
  13. Medical Records:  I agree to create a patient portal with LabCorp for copies of lab reports to obtain copies of my labs.  I agree to make a verbal request for chart notes prior to my consultation at which I will obtain said records.  In the event I am no longer able to receive consultations (e.g. I moved out of the service area), I will speak directly to the receptionist about the means by which I can obtain medical records should I need them.  I understand that there will be a charge for obtaining medical records and I agree to pay that fee prior to receiving my records.  The doctor will automatically provide a copy of the imaging reports at my follow-up consultation.  It is my responsibility to keep all of my medical records.  I understand that if I am seeking SSI/SSDI/disability, workers’ compensation, or other litigious administrative services, I will not use the services of Affordable Mobile Doctor.  I understand that I will not use a third party to request medical records. 
  14. HIPPA NOTICE OF PRIVACY PRACTICES: I have read and understood the HIPPA NOTICE OF PRIVACY PRACTICES and have access to this information.  I have had the opportunity to ask questions.
  15. Consent to Diagnosis and Treatment:  Receiving service from the doctor means I have read and understood the above and have had an opportunity to ask questions.  I hereby consent to treatment.