New Clients

I. Basic Information

Please fill out the required fields below to become a new client of ours. We are grateful and feel blessed that you are choosing Aquarius Medical Spa to help fullfill your medical and wellness goals. *Required

Please enter your first name*

Please enter your last name*

Please enter your email address*

Select Preffered Clinic*

Please enter your mailing address*

Please enter your city*

State*

Please enter your zip code*

Country*

Please enter your phone number (###-###-####)*

Please enter your birthday (MM/DD/YYYY)*

Gender*

Marital Status

Please provide a reference for emergency contact, should such an event occur. *Required

Please enter your emergency contact first name*

Please enter your emergency contact last name*

Please enter your emergency contact phone number*

II. Wellness Interest(s)

Please select which services you are most interested in.

III. Health History

For medical history select “C” for current problems and “X” for any problems that occurred in the past. Otherwise if neither, choose "Never an Issue". *All Fields Required

Bloody or Tarry Stools*

Frequent Ear Infections*

Convulsions/Seizures*

Double Vision*

Abdominal Pain (Chronic)*

Urinary Infections (Frequent)*

Sore Throat (Frequent)*

Hay Fever/Allergies*

Hoarseness (Prolonged)*

Bronchitis/Chronic Cough*

Moodiness (Excessive)*

Shortness of Breath*

Sleeping Difficulty*

High Blood Pressure*

Change in Bowel Habits*

Overnight Urination (2+Times)*

Decrease in Force of Urination*

Numbness/Tingling Sensations*

Bone Fracture/Joint Injury*

Varicose Veins/Phlebitis*

Loss of Appetite*

Difficulty Swallowing*

Indigestion/Heartburn*

Mental Illness*

Palpitations*

Irregular Pulse*

Weight Loss (Recent)*

Peptic Ulcers*

Constipation*

Memory Loss*

Ringing in Ears*

Nervousness*

Hemorrhoids*

Dizzy Spells*

Sinus Problems*

Bruise Easily*

Blood in Urine*

Kidney Stones*

Thyroid Disease*

Heart Murmur*

Asthma/Wheezing*

Painful Urination*

Venereal Disease*

Chronic Fatigue*

Muscle Weakness*

Headache (Frequent)*

Arthritis/Rheumatism*

Back Pain (Recurrent)*

Jaundice/Hepatitis*

Cold Numb Feet*

Gall Bladder Trouble*

Fainting Spells*

Depression*

Anemia*

Cancer*

Diabetes*

Stroke*

Foot Pain*

Hives*

Eczema*

Phobias*

Hernia*

Eye Pain*

Diarrhea*

Chest Pain*

COVID-19 (Complications)*

IV. Basic Immunization History

For immunization history, please answer the following questions below. In doing so, this will help us get a better understanding of how to best address your issues. All information is encrypted and we will not share this information with any third-party. We treat and respect all clients equally whether they have been immunized or not. *All Fields Required

	Influenza Vaccine (Flu Shot)	Covid-19 Vaccine
	Flu Shot*	COVID-19 Shot*
		# of COVID-19 Boosters Received*
		COVID-19 Vaccine Manufactuer*

V. Family Medical History

Please check the boxes that list any medical issues your family has had that you know of. This includes your mother, father, brother(s), sister(s) and grandparents. If your not sure, leave boxes un-checked.

VI. Drug Allergies

Please declare if you have any drug allergies and if so, list the name(s) of the drugs. If you are allergic to more than (3), we can document this upon your visit.

	Yes	No	Names of Drugs Allergic To
Drug Allergy

VII. Prescription Medication(s)

Please list the prescription medications that you are currently using on a regular basis. We allow up to (9) medications. If you are taking more than (9), we can document this upon your visit.

VIII. Social History

Please indicate whether you drink and/or smoke tobacco products, use vapes, cannabis or recreational drugs on a regular basis. A regular basis can be defined as using more than (3) days per given week.

	Yes	No
Consume Alcohol
Use Tobacco Products
Use Vape Products (Nicotine)
Use Cannabis Products
Recreational Drugs (Cocaine, Meth, etc.)

IX. HIPPA Policy & Personal Health Information (PHI)

Please read the HIPPA documentation and our policies here at Aquarius Medical Spa. Once read, please electronically check the box that you have read the policies and electronically sign the form.

The Department of Health and Human Services has established a "Privacy Rule" to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients' consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations.

As our patient we want you to know that we respect the privacy of your personal medical records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal medical records. We may have indirect treatment relationships with you (such as laboratories that only interact with physicians and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent.

You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). If you choose to give consent in this document, at some future time you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or a previously signed consent.

If you have any objections to this form, please ask to speak with our Medical Director. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice.

Additionally, the misuse of Personal Health Information (PHI) has been identified as a national problem causing patients inconvenience, aggravation, and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the “Privacy Rule.” We strive to achieve the very highest standards of ethics and integrity in performing services for our patients.

It is our policy to properly determine appropriate use of PHI in accordance with the governmental rules, laws and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent any inappropriate use of PHI.

We also know that we are not perfect! Because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel that an event in any way compromises our policy of integrity. More so, we welcome your input regarding any service problem so that we may remedy the situation promptly.

I Have Acknowledged & Read Aquarius Medical Spa's HIPPA Policy

Please enter your full name to electronically sign*

X. Informed Consent to Provide Services

Please read the Informed Consent to Provide Services documentation and our policies here at Aquarius Medical Spa. Once read, please electronically check the box that you have read the policies and electronically sign the form.

This consent is required by the Health Insurance Portability and Accountability Act of 1996 to inform you of your rights for privacy with respect to your health care information.

Consent Related to Privacy Notice: I have had a chance to review the Practice Privacy Notice (HIPPA/PHI) as part of this registration process. I understand that the terms of the Privacy Notice may change and I may obtain these revised notices by contacting the practice by phone or in writing. I understand I have the right to request how my protected health information (PHI) has been disclosed. I also have the right to restrict how this information is disclosed, but this practice is not required to agree to my restrictions. If it does agree to my restrictions on PHI use, it is bound by that agreement.

Consent for Care: I, with my electronic signature, authorize (this practice), and any employee working under the direction of the physician, to provide medical care for me, or to this patient for which I am the legal guardian. This medical care may include services and supplies related to my health (or the identified person) and may include (but not limited to) preventative, diagnostic, therapeutic, rehabilitative, maintenance, palliative care, counseling, assessment or review of physical or mental status/function of the body and the sale or dispensing of drugs, supplements, devices, equipment or other items required and in accordance with a prescription. This consent includes contact and discussion with other health care professionals for care and treatment. I realize there are inherent risks with the care I may receive. Given these inherent risks, and by authorizing consent for care, you also hereby release any and all liability, to individuals providing care for you under Aquarius Medical Spa. In the event a dispute arises over the outcome of the treatment, I consent solely to arbitration according to the standards set forth by the American Arbitration Association as a legal means of settlement.

Consent for IV Therapy: I, hereby give consent to Aquarius Medical Spa to perform intravenous vitamin and mineral therapy. I understand that intravenous nutrient therapy is not standard, widely approved or accepted for the purpose(s) of treatment of prevention of disease and the view that it is of benefit in the treatment of such disorders is accepted by a minority of the medical community and is considered "experimental" by most physicians. I am advised that other treatment approaches have been used in these conditions, including but not limited to prescription medications, over-the-counter drugs and nutritional supplements and these alternatives have been explained to my full satisfaction.

I understand that the benefits of intravenous nutrient therapy are much greater if I follow a healthy lifestyle (non-smoking, weight control, proper exercise, proper diet and nutritional supplementation). I understand that an initial series of treatments are anticipated and that these treatments may extend over a number of weeks or months. I understand that it is my option to stop at any time with this treatment protocol without incurring any further expense after I have directed that such treatment be stopped. As with any other medical procedure, a small percentage of clients do not respond to this therapy.

I have been informed of possible risks and side effects including but not limited to discomfort at the injection site, thrombophlebitis, fatigue, allergic reaction, congestive heart failure, lowering of blood sugar levels, fever, and chills and generalized complaints. I understand that this therapy should not be used if I am pregnant unless I have severe life threatening disease. I understand the nature of the proposed therapy and the risks and dangers have been explained to me to my full satisfaction.

While I understand that there have been no warranties or guarantees of successful treatment made to me, I desire to undergo this treatment after having considered the information contained in this document, the information provided to me through conversations and materials that may be provided to me by the office to educate me about the treatment. I acknowledge that I have had the opportunity to ask questions and with respect to my proposed therapy and the treatments to be utilized and all my questions have been answered to my full satisfaction. my signature on this agreement will constitute a full and final release of any legal responsibility resulting from the administration of intravenous nutrient therapy in my case and/or any other medical treatments that may be necessary as a result thereof.

Consent for Release of Information and Assignment of Benefits: I also authorize this practice to furnish information to the identified insurance carrier(s) for any and all payment activities. I consent to assign all payments for services directly to this practice. I further consent to the use for any practice operational needs as identified in the Practice Privacy Notice.

Financial Policy: We appreciate you choosing us for your healthcare. We will adhere to the following financial policy in order to consistently deliver high quality care and services. The patient/responsible party assumes responsibility to ensure that the financial obligation is fulfilled for the health care services received. I understand that I am responsible for all co-payments, amounts applied to deductibles, and other amounts that may be deemed my responsibility by the payment sources, as required by my contract with my insurance plan and state regulations.

I understand that if I have an insurance co-payment, I am expected to make payment when checking in for my appointment. I understand that my contract with my insurance entity may or may not cover some services. All insurance policies are not the same. They vary by employer group. Aquarius Medical Spa and its staff are not responsible or able to know every policy available. It is my responsibility to verify applicable coverage prior to receiving the services. For example, not all health plans include screenings as a benefit. If I seek care outside of the contract terms, I am aware that I may be responsible for all charges that are incurred.

Thank you for your understanding and cooperation with this policy. It is our privilege to provide your medical care. I have read and understand the Consents and Financial Policy stated above and agree to accept full responsibility as described above.

I Have Acknowledged & Read Aquarius Medical Spa's Informed Consent Policy

Please enter your full name to electronically sign*