I certify that the above information is correct to the best of my knowledge. I will not hold my doctor or any members of his/her staff responsible for any errors or ommissions that I may have made in the completion of this form.
CONSENT FORM FOR TREATMENT & THERAPY
By ACCEPTING this CONSENT, you agree that LV Institute of Preventive
Medicine, Inc. and his/her assistants have your permission to
manage your treatment & therapy program as deemed necessary.
All therapeutic procedures involve some risk, including failure
to receive the desired result or to obtain the information sought.
Although your doctor is the best source of information as the
risks involved, LV Institute of Preventive Medicine, Inc. is a
partnership between doctor and patient which requires you to accept
designated responsibility for carrying out your part of the program.
Please be sure that you receive or request full information before
accepting this form. You are entitled to be fully informed by
your doctor about the nature of the therapy, it's purpose, it's
anticipated benefits, possible side effects, available alternatives,
independent economic interests of your doctor, if any, and all
known or reasonable forseeable risks involved.
Your ACCEPTING on the CONSENT means: (1) You have read and understand
this information contained herein; (2) you have been informed
by your physician about the nature and risk of this therapy; (3)
you were provided with an opportunity by your physician to ask
questions about this therapy; and (4) you consent to the treatment
& therapy program.
Fax a copy of
your last physical examination to Dr. Brumfield. Fax the name
of a medical laboratory in your area and their fax number.
(Our fax is 702-876-7459)
(Dr. Brumfield will fax an order to your local laboratory that
is coded for insurance coverage. Take your insurance cards to
the laboratory. The tests ordered may include: 1) Blood chemistry,
lipid panel, CBC, T 4) Somatomedin-C (HGH level) 3) PSA (prostate
screen, men) 4) Testosterone, serum (men & women) 5) Estrogen,
serum (women & obese men) 6) Progesterone, serum (women) 7)
DHEA-S (men & women)
There is a one
time charge of $500. Your account will be charged $100 now for
Dr. Brumfield to review all your medical records and laboratory
tests, and $400 upon completion and mailing your individualized
program package. Let's get started. We are your partner's in good
health.
