AGREEMENT FOR INTEGRATIVE APPROACH TO HEALING PSORIASIS
1. I understand that the first 15-minute introductory phone call is free. I fully understand that if I proceed with scheduling educational sessions with Dr. Peretz that this form constitutes my agreement to purchase one or more direct 50-minute one-to-one, Skype, or FaceTime education sessions with Christina Peretz, M.D. to discuss my diagnosed psoriasis and a possible integrative approach to its healing. I represent that I have already been diagnosed withpsoriasis by a physician qualified to make that diagnosis as it is one that can be complicated and must be made by aphysician qualified in that field. I will not rely on Dr. Peretz to make such a diagnosis.
2. I fully understand that, though Dr. Peretz is a licensed physician in California, the education sessions I am purchasing will not involve the provision of medical care or advice as, in order to provide medical care or advice, Dr. Peretz would require a full medical history, a complete physical examination, and the review and interpretation of any indicated diagnostic testing as well as possible collaboration with other specialists. I understand that Dr. Peretz does have a medical practice through her clinic in San Francisco and, should I at some time want to undertake medical care, I will request that Dr. Peretz make an appointment for me in her practice. I am aware that she may not have an opening in her medical practice and therefore does not guarantee that I can obtain an appointment, but I understand that she is not offering medical care or advice in connection with the services provided under this agreement.
3. I understand that, by contrast with medical care or advice, my education sessions under this agreement will involve the gathering of my general health information and future objectives through a generalized questionnaire rather than the taking of a comprehensive medical history pertaining to signs and symptoms of illness, and does not involve any kind of physical examination or diagnostic testing, and for that reason cannot involve any medical care, diagnosis, treatment or advice. My education session will rather involve the provision of general education and recommendations concerning health, wellbeing, and lifestyle based upon the general information obtained and is not intended in anyway as a substitute for medical care and advice. Therefore, as I cannot and will not rely on any recommendations from Dr. Peretz as medical care or advice, I agree to consult directly and regularly with a primary care doctor in my local vicinity who will in fact provide all my medical advice and manage all my medical care and treatment during the time I am working with Dr. Peretz. I understand that no physician-patient relationship will exist between Dr. Peretz and me and I agree to submit all medical questions to my physician(s), not to Dr. Peretz, and will not defer, delay or refrain from obtaining medical care from my physician(s), nor ignore my physician’s medical advice, based upon any interaction with Dr. Peretz. I agree that Dr. Peretz will not be liable for any damages or injuries that occur to me from any medical condition of any kind and I waive any claim in connection with the provision of any medical service or the failure to provide any such service.
4. I understand that the educational sessions will involve discussion of various means of addressing psoriasis, for example, by way of diet, meditation, mind/body techniques, the healing properties of sun and water, as well as supplements. Dr. Peretz will make suggestions as to how to integrate these various aspects into my life. Prior to beginning the session, I will be asked to submit an informational questionnaire comprised of background questions that will assist in initiating the educational discussion with Dr. Peretz. In addition, there is a series of video sessions, three times per year, that are being planned and, when developed, will be presented by webinar through Facebook or a computer chat room, in which Dr. Peretz will participate.
5. I understand Dr. Peretz will not be available for questions except during scheduled follow-up sessions.
6. Should I wish to change a scheduled session time I will have one such re-scheduling without charge if arrangements are made 72 hours or more in advance.
7. I understand that if I miss my scheduled session, or cancel with less than 72 hour notice, I am liable for the full amount of the scheduled appointment. If I reschedule another session within 3 months the fee will be applied to the new session, otherwise it will be forfeited and a new fee will be charged.
8. I understand that I must complete the informational questionnaire above. I understand that this questionnaire will be retained by Dr. Peretz during the education sessions and suggestion process, but that it is not a medical record and is not subject HIPAA (Health Insurance Portability and Accountability Act) requirements. I understand that Dr.Peretz will not knowingly disclose information provided, but that no special confidentiality precautions will be taken beyond that, so that I will not provide any confidential medical information in the questionnaire.
9. I understand that Dr. Peretz will tape record some of the conferences and, if she does so, she will provide me with a copy of each tape that I may retain to refer to as necessary for purposes of recalling the discussion and for assistance in my formulating questions for consideration in the next session.
10. By signing this Consent and Agreement I agree that I understand and agree to all the principles set forth herein, that I have asked questions of Dr. Peretz to resolve an aspect that I did not understand, and that I will ask questions in the future to resolve any question I have concerning the education sessions and suggestions. Further, by signing this agreement I agree to submit any dispute of any kind that arises from the relationship covered by it to arbitration which will be brought in the State of California, that I agree to be subject to the jurisdiction of the California courts, and that any such dispute will be governed by the laws of the State of California.
11. This shall be the entire contract between Dr. Peretz and me and by signing it, in addition to the agreements set forth above, I agree to pay for the services covered by it, and that my credit card set forth below may be charged for all amounts connected with such services. I understand that I am responsible personally for all charges and that if I wish to obtain reimbursement from any insurer or other provider, governmental or non-governmental, employer or otherwise, I will pursue such reimbursement and Dr. Peretz will not be responsible in any manner for such submissions.