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Informed Consent

Informed Consent

Patient Conditions of Treatment and Informed Consent to Treat

This document is a binding agreement (the “Agreement”) between Denali Performance Clinic Services/Denali Performance Clinic and/or (We” “Us”) and the individual patient whose name and signature appears below (“You” “Your”). In consideration of the health care services provided to You by Us at the present and at all times in the future, You agree as follows (Your agreement indicated by checking the box in each section and by signing in the space provided):

1. Consent For Treatment. You hereby consent to and authorize Us to provide You with health care treatment, including without limitation medical, diagnostic, Phlebotomy, NeuroMuscular Optimization, Frequency Specific NeuroElectrical Stimulation, Pulsed ElectroMagnetic Field treatment, Laser Treatment, Instrument assisted soft tissue nasal treatment, nutritional treatment, Intravenous Micronutrient Therapy, Prolotherapy and RenuO2 (together the “Treatments”) administered by Us, our physicians, assistants, consultants and staff. You understand that the practice of healthcare is not an exact science and that diagnosis and treatment may involve risk of injury or death. You acknowledge that We have not made any guarantees or promises as to the outcome or the safety and efficacy of the Treatment.

2. Risks, Side Effects, Complications. Although rare, and considered low risk we hereby inform You that there are certain unavoidable risks and potential side effects and complications to the Treatments, including without limitation infection; swelling; increased pain; bleeding; scarring; scar or wound enlargement; keloid formation; asymmetry; temporary or permanent alteration in sensation; allergic reaction; discoloration; the need for additional surgery; soreness, itching, infection, injury to nerves, internally and externally leaking fluid and scaring at injection sites (all of which except the leaking fluid may be permanent); a feeling of “lumpiness” or permanent skin contour irregularities at the site of Treatments; spinal cord injuries, Pneumothorax (air on the outside of the lung), paralysis, dizziness, numbness, no benefit from Treatments; or other serious or debilitating injuries or death.

3. Description of Treatments. Treatment may consist of appropriately applied neuroelectric electrodes, injections using needles, IV catheter insertion and nutrition infusion, pressure points with the intent of muscle activation. You acknowledge that the Treatments may involve insertion of needles into Your skin and veins and the injection of standardized formulas which may include various nutritional substances, homeopathic medicines, and FDA approved prescriptive medicines, local anesthetic (Procaine or Lidocaine), concentrated sugar water or dextrose, and ozone therapy and local subcutaneous anesthetic infiltration. The exact solution and site of injection for Your Treatment, as well as the recommended sequence of Treatments, will be explained to You when We administer the Treatments.

4. Experimental Nature of Treatment. You acknowledge and agree that the evaluation, diagnosis and treatments may consist in whole or part of what the FDA may consider experimental procedures and methods, including without limit Intravenous Micronutrient Therapy, Prolotherapy and Mesotherapy, on which no governmental (including the U.S. Food and Drug Administration (“FDA”)), scientific or medical authority has issued any guidelines or statements as to the safety or efficacy thereof. You acknowledge that the safety record of the Treatments is based only on empirical and anecdotal evidence, which only shows that the Treatments appear to be relatively safe. We have informed You that the Treatments MAY alter, address or decrease Your pain, symptoms or complaints, but also may have no effect.

5. Healthcare Staff. You are aware that among those who attend You on Our behalf are medical, nursing, and other healthcare personnel in training, who unless requested otherwise, may participate in patient care as part of their education. You further consent to the presence of service representatives and/or technicians from manufacturers of equipment or devices to assist in performing and/or operation of such equipment and/or devices during operation, procedure and Treatments.

6. Alternatives. You understand and have been informed that there are alternatives to the Treatments including surgery, other types of injections, prescription medications, massage, stretching and taking no action.

7. Information You Provide Us. You have provided Us with a Complete list of all prescription and non-prescription medications and dietary supplements You are currently taking, and You agree to update Us periodically should this list change. You have provided Us with a complete list of all known allergies You may have, and all allergic or adverse reactions You have had in the past to any medicines, dietary supplements or medical treatments of any kind. You confirm that all the information You provide Us during the course of Treatments, including the information required by this Section 6, is true, accurate, complete and up-to-date to the best of Your knowledge. Your e-mail has been provided for the purpose of schedule reminders and clinic updates.

8. Assumption of Risk. You hereby acknowledge that after having read carefully and understood fully the terms of this Agreement, and after having adequate time to ask any questions about this Agreement or the Treatments that You have, You are willing to assume any and all risks associated with the Treatments, including without limitation to those described in this Agreement. You acknowledge that no explanation or description of the Treatments can ever fully explain every possible risk, side effect or complication that may or could arise from the Treatments, but that by signing this Agreement, You nevertheless acknowledge Your willingness to assume such risks and that Your consent to the Treatments is willing, voluntary and informed.

9. Miscellaneous. You agree that this Agreement constitutes the entire agreement between You and Us regarding the subject matter hereof. No promise, representation, guarantee or warranty not included in this Agreement has been or is being relied upon by you. This Agreement shall be binding on You and Your successors, heirs, legal representatives and assigns. In case any one of the provisions of this Agreement is held invalid or illegal, such provision shall be curtailed, limited or severed only to the extent necessary to remove such illegality or invalidity. This Agreement shall be governed by the laws of the state of Utah without regard to any choice of law principal.

10. Financial Agreement. You have reviewed, initialed and signed the financial agreement for Denali Performance Clinic.

I am either the patient or the patient's legally authorized representative consenting to the treatment on the patient's behalf. By signing below, I acknowledge that I have read through the above information, and confirm understanding and compliance.

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July 9, 2019 7:29 am MDT

Informed Consent Uploaded by Lisa Strauss - accounts@denalimed.com IP 107.191.0.119

July 10, 2019 8:41 pm MDT

Cindy Meldrum - cmeldrum@denalimed.com added by Lisa Strauss - accounts@denalimed.com as a CC'd Recipient Ip: 107.191.1.119

July 11, 2019 12:40 pm MDT

Cindy Meldrum - cmeldrum@denalimed.com added by Lisa Strauss - accounts@denalimed.com as a CC'd Recipient Ip: 107.191.1.119