The Health Part

As you can imagine, results on a program of this nature vary and cannot be guaranteed. Recommended supplements, herbs, etc. are intended to work with specific diet/lifestyle changes, which are a critical part of the process. (So no cheating!) In general, you will get out of it what you put in.

All supplements, vitamins, herbs recommended are generally considered safe, however, some can interact with certain medications, so please consult with your prescribing physician before beginning program. If currently taking medications, please don't stop without consulting with your doctor. If you have a high/low blood pressure or sugar, please monitor it carefully because as your health improves, you may need to speak with your doctor about adjusting medications accordingly. Every precaution is taken to ensure safety. Our programs and supplements have helped thousands achieve their goals, however, we cannot predict how each person will respond to each supplement (allergies, etc.). Therefore, you are acting at your own risk. Please advise us and your doctor if necessary, if you experience any unpleasant or unanticipated side effects including gastrointestinal upset, allergic reactions, etc. We do not diagnose or treat diseases including but not limited to diabetes, heart disease, cancer, autoimmune, thyroid disease, etc. We treat people. Your signature indicates that you authorize the staff to perform any necessary services, and that the above information was completed correctly to the best of your knowledge. It is your responsibility to inform this office of any changes to the information you have provided.

The Unavoidable Money Part (if purchasing a program)

Your signature below indicates that you understand that you are solely responsible for any treatment rendered in this office. We cannot accept insurance for weight loss services.

The Most Important Part

Ultimately, great communication is the key to any great, long lasting relationship. If something is on your mind, from symptoms you experience to ways we can improve our services, please let us know! You can reach Dr. Infantino directly on his cell number 480-452-8355 to share a win, make a suggestion or just to give him feedback. We truly look forward to serving you. Welcome to our family!

By signing this Consent, I acknowledge and provide permission to Platinum Wellness (Practice) as follows:

1. Platinum’s Privacy Notice has been provided to me prior to my signing this Consent. The Privacy Notice includes a complete description of the uses and/or disclosures of my protected health information(“PHI”) necessary for the Practice to provide treatment to me, and also necessary for the Practice toobtain payment for that treatment and to carry out is health care operations. The Practice explained to me that the Privacy Notice will be available to me in the future at my request. The Practice has further explained my right to obtain a copy of the Privacy Notice prior to signing this Con-sent, and hasencouraged me to read the Privacy Notice carefully prior to my signing this Consent.

2. The Practice reserves the right to change its privacy practices that are described in its Privacy Notice,in accordance with applicable law.

3. I understand that, and consent to, the following appointment reminders that will be used by Platinum Wellness: a) Text messages sent to me at the phone number provided by me; and b) telephoning my home and leaving message on my answering machine or with the individual answering the phone. c) Emails sent to me at the email address provided by you.

4.The Practice may use and/or disclose my PHI (which includes information about my health or conditionand the treatment provided to me) in order for the Practice to treat me and obtain payment for thattreatment, and as necessary for the Practice to conduct its specific health care operations.

5. I understand that I have a right to request that the Practice restrict how my PHI is used and/or dis-closed to carry out treatment, payment and/or health care operations. However, the Practice is notrequired to agree to any restrictions that I have requested. If the Practice agrees to a requested restriction, then the restriction is binding on the Practice.

6. I understand that this Consent is valid for seven years. I further understand that I have the right torevoke this Consent, in writing, at any time for all future transactions, with the understanding that any suchrevocation shall not apply to the extent that the Practice has already taken action in reliance on this consent.

7. I understand that if I revoke this consent at any time, the Practice has the right to refuse to treat me.

8. I understand that if I do not sign this Consent evidencing my consent to the uses and disclosures described to me above and contained in the Privacy Notice, then the Practice reserves the right to not treat me.

I have read and understand the health information disclosure and protection in the foregoing notice.