You are allowed to cancel or reschedule your appointment--free of charge-- up to 24 hours prior to your scheduled time slot.
cancellations within 24 hours prior to the appointment and no shows are non-refundable.
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I consent to allow Dexafit Boston and/or DexaFit, Inc. to use their DXA scanner to perform a body composition and/or bone densitometry scan, with full awareness that the technology uses low-dose x-rays.
RECORDS REVIEW FOR RESEARCH
I also authorize Dexafit Boston and/or DexaFit, Inc. to use or review my de-identified records for research purposes and/or to determine my qualifications for approved clinical studies and to contact me if I have potential as a research candidate.
I accept financial responsibility for all charges for services provided to me and/or my family members.
WAIVER AND AGREEMENT
1. I do hereby release all representatives of Dexafit Boston and/or DexaFit, Inc. that are acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in services, activities, or programs of Dexafit Boston and/or DexaFit, Inc.
2. I am voluntarily participating in the Dexafit Boston ] and/or DexaFit, Inc DXA scan service and/or other including 3D scan, RMR and VO2max Metabolic Analysis. I hereby agree to expressly assume any and all risks of injury and death resulting from participation in the aforementioned services.
3. I further hereby declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that disqualifies me from receiving a DXA scan from Dexafit Boston and/or DexaFit, Inc. I acknowledge that I have permission to participate or that I have decided to participate in these services without the approval of my physician and do hereby assume all responsibility for my participation. I also certify that I am not pregnant or trying to become pregnant.
4. I take full responsibility for any action taken by me after my visit to Dexafit Boston and/or DexaFit, Inc. I do not hold any representatives of Dexafit Boston or DexaFit, Inc responsible or liable for any adverse effects or complications arising from the services or opinions offered by them.
5. Confidentiality. The information based on the observations made during the DXA scan, VO2max, or RMR analysis, and subsequent report is treated as privileged and confidential. However, it may be used for statistical or scientific purposes with your right to privacy retained.
6. I understand that Dexafit Boston and/or DexaFit, Inc does not diagnose or interpret the DXA results, and that any further review or analysis of the report is between the individual and their primary care physician.
CLIENT HIPAA CONSENT FORM
‘I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize Dexafit Boston and/or DexaFit, Inc to use and disclose my protected health information to carry out:
Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
Obtaining payment from third party payers (e.g. my insurance company);
The day-to-day operations of Dexafit Boston practice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.
I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
I hereby authorize Dexafit Boston and/or DexaFit, Inc to forward the health and fitness information resulting from their services to me or any parties authorized by me by means of email, fax, mail, or through the private login page on the DexaFit website. I also understand that this Authorization
is subject to revocation/withdrawal by me at any time in writing to Dexafit Boston, except to the extent that the action has already been taken to release this information. This Authorization shall remain valid unless revoked. Dexafit Boston and/or DexaFit, Inc will not forward my health and fitness information if I do not consent to this Authorization.
Consent Form for VO2max:
1. Purpose and Explanation for the Test
You will perform a graded exercise test on a motor-driven treadmill or stationary bike. The exercise intensity will begin at a low level and will be advanced in stages, depending on your fitness level. We may stop the test at any time because of signs of fatigue or changes in your heart rate or blood pressure, or symptoms you may experience. You may stop the test at any time because of feelings of fatigue or any type of discomfort.
2. Attendant Risks and Discomforts
As with any exercise, there exists the possibility of certain changes occurring during the test. These include abnormal blood pressure, fainting, irregular, fast or slow heart rhythm, and in rare instances, heart attack, stroke, or death. Please note that there will NOT be a physician present on site.
3. Responsibilities of the Participant Information you possess about your health status or previous experience of exercise-related or heart-related symptoms (such as shortness of breath with low-level physical activity, pain, pressure, tightness, or heaviness in the chest, neck, jaw, back, and/or arms) may affect the safety of your test. You are responsible to consult with your own doctors before taking the test to assess the safety for the test for you.
4. Benefits to be Expected
5. Inquiries Any questions about the procedures used in the exercise test or the results of your test are encouraged. If you have any concerns or questions, please feel free to ask via email at firstname.lastname@example.org prior to the test
I hereby consent to engage in an exercise test to determine my exercise capacity. My permission to perform this test is given voluntarily. I understand that I may stop the test at any point, if I so desire. I have read this form and I understand the test procedures that I will perform and the attendant risks and discomforts, which includes injury or death. I understand that there will NOT be a supervising physician onsite. Knowing these risks and discomforts, and having an opportunity to ask questions that have been answered to my satisfaction, I consent to participate in the test.