Waiver of Liability & Informed Consent First Name* Last Name* Phone*Email* Please check box as your affirmation to the following statements:* I understand that Julie Stapleton, MD is Board Certified in Physical Medicine and Rehabilitation. I understand that Julie Stapleton, MD will NOT act as my primary care physician. I understand that I, as a patient, will be responsible for follow-up care with my primary care physician. If I do not have a primary care physician, I will ask the office staff of Julie Stapleton, MD for a referral to a primary care physician. I understand that all information provided to this medical facility will remain confidential. I understand that a consulting physician, Julie Stapleton, MD will review my medical history and any pertinent laboratory findings to make an informed decision concerning diagnosis and treatment of my condition(s). I will be responsible for providing honest and accurate responses to all questions. Before taking any prescribed or recommended treatment, medications or therapy, I will have a complete physical within the last six months, and report any findings that are outside the “normal range”, or that may interfere with the usage of the prescribed or recommended treatment, medications or therapy. I understand that there are no guarantees that the treatment, medications or therapy will provide the result(s) I am seeking. I understand that payment is due prior to service. I understand that services are NOT reimbursable through insurance companies or Medicare. As I know the treatment at Rocky Mountain Hyperbaric Institute is experimental and that many improvements may or may not show up on general physical exams. Date* MM slash DD slash YYYY This form collects personal information so we can contact you to discuss your request. Take a look at our privacy policy for the full story.* I understand by submitting this form I agree to the privacy policy. * I understand that Rocky Mountain Hyperbaric Institute will use this information to contact me regarding my inquiry. CAPTCHA
