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Consent

INFORMED CONSENT AND MEDICAL RELEASE FORM Vibrational Vitality, LLC (“Vibrational Vitality”) and its network of healthcare providers, fulfillment partners, and laboratories provide healthcare that may be nontraditional or unconventional. Such services and products are commonly referred to as complementary or alternative medicine, holistic, or innovative services. Vibrational Vitality services may include nutritional and herbal products and consultations, prescription medication, IV Therapies, supplementation, alternative approaches to health and wellness, and innovative laboratory testing (e.g., blood, genetic, gut, etc.) and diagnosis. Some of the foregoing services may not be medically necessary or recognized as the standard of medical practice or care in your state or country. While long practiced, such services may be considered investigational or experimental by the conventional medical community. Certain Vibrational Vitality products or services may have their consent forms and/or terms and conditions. If you elect to receive any of these products or services, you hereby agree to be bound by the applicable form. By signing below, accepting these terms electronically or electing to receive services and products from Vibrational Vitality, I, as the customer or parent/legal guardian of the customer (“I” “Me” or “Customer”), understand that I am voluntarily entering into this informed consent and medical release form, including any attachments (collectively “Form”). I hereby expressly agree and consent to the following:
  1. I consent to the release of my blood/genetic/gut/other lab results to Vibrational Vitality, the Vibrational Vitality network of healthcare providers and third-party laboratories, and any other person I authorize, to allow the provision and completion of the services and to allow the provider(s) to review my results and conduct a follow up consultation if I so choose. Schedule 1 lists Vibrational Vitality’s current lab and fulfillment partners and may be updated at Vibrational Vitality’s discretion.
  2. I consent to allow Vibrational Vitality and its network of healthcare providers and laboratories to access my entire medical history, including my medication history.
  3. I certify I am at least 18 years old.
  4. I certify I have had the opportunity to read and consider the Vibrational Vitality System Privacy Policy and Terms of Service to my satisfaction before entering this Form.
  5. I accept that the Vibrational Vitality services, including counseling/explaining of results, may be rendered in a telehealth setting, a Vibrational Vitality clinic, a concierge visit, or via an independent laboratory (e.g., LabCorp).
  6. I understand that, as with any medical procedure, there are potential risks and discomforts associated with Vibrational Vitality products and services. These may include: • Temporary pain or discomfort at the site of needle insertion • Bruising or swelling at the puncture site • Infection, although rare, at the puncture site • Fainting or dizziness during or after the test • Rarely customers may experience the following: Inflammation of the vein used for injection, phlebitis, metabolic disturbances, and injury • Extremely Rarely customers may experience the following: Severe allergic reaction, anaphylaxis, infection, cardiac arrest and death.
  7. I have been provided with an opportunity to ask questions about all Vibrational Vitality products and services, and my questions have been answered to my satisfaction. I understand that this consent is voluntary, and I have the right to refuse or withdraw consent at any time before or during the services, provided I understand I may not.
  8. REVOCATION: I understand that I have the right to revoke this authorization, as it pertains to my personal information, at any time. If I revoke this authorization, I understand that I must do so in writing by emailing [email protected] or by mail at: Vibrational Vitality LLC, 2022 Carnes Street, Orange Park, Florida 32073.
  9. I understand that the revocation (a) may affect my ability to receive services from Vibrational Vitality that require such personal information and (b) will not apply to personal information that has already been released in response to this authorization. Vibrational Vitality | www.vibrationalvitality.com | (904) 385-0497 This authorization will automatically expire one (1) year following the date of signature, except that this authorization will expire automatically after ninety (90) days if it pertains to my complete medical record.
  10. I understand that the medications I am being prescribed are solely for me based on diagnoses derived from my submitted medical history, blood/genetic/gut/other lab work, and/or a physical examination, and such medications shall be used only by me and exclusively by state and federal law.
  11. I agree that these medications are solely for my personal use and that I will not share, sell, or trade my medications with any other person or entity. I agree that I will safeguard my medications from loss or theft and will be responsible for their safekeeping.
  12. I agree that I will use my medications at the prescribed rate and dosage and will keep the medication in its respective labeled container.
  13. I acknowledge that Vibrational Vitality supplements and medications may not be NSF certified. Therefore, if I am a professional athlete, collegiate athlete, or if I am otherwise subject to any other restrictions, I agree that I will consult my personal and/or team physician before the use of any Vibrational Vitality supplements or medication. I further understand and agree that the medication is not being prescribed for me for bodybuilding, performance enhancement, or physical appearance, and I agree to not attempt to use it for any of these purposes.
  14. I acknowledge that I have the right to receive my prescribed medication at the pharmacy of my choice, provided my medication is available at such a pharmacy and I can receive a prescription from my primary care provider.
  15. I agree that I will not attempt to obtain additional or other medications from any other health care practitioner or source without first disclosing my current medication usage to Vibrational Vitality, my treating healthcare provider, through Vibrational Vitality, and any other physician, pharmacy, or source. I understand that in addition to endangering my health, I may also be violating the law if I fail to make this disclosure.
  16. Having been informed of the potential risks of hormone replacement therapy, I voluntarily assume any risks that may be associated with engaging in hormone replacement therapy.
  17. I have discussed and understood the risks and benefits associated with Vibrational Vitality products and services, and I agree that I will immediately report any adverse side effects related to the use of my medication to Vibrational Vitality and discontinue use until advised to resume usage by a healthcare provider. If I elect to receive intravenous therapy (commonly referred to as an IV) or intramuscular (IM) vitamin injections, I hereby acknowledge that I have discussed the benefits and risks of IV and IM therapy.
  18. I understand that most, if not all, products and services offered by Vibrational Vitality are not evaluated by the FDA. Vibrational Vitality products and services are not intended to diagnose, treat, cure, or prevent disease.
  19. I understand that, for an additional fee, the healthcare providers in the Vibrational Vitality healthcare provider network are available for questions and/or concerns during normal business hours throughout my treatment.
  20. I agree and understand that any returns, replacements, and refunds will be subject to Vibrational Vitality’s Refund Policy.
  21. I understand that these programs are not covered by insurance. I understand that I am responsible for paying for all services and products, and I will pay for all such products and services in advance. I will not directly or indirectly seek reimbursement through my insurance company, Medicare, Medicaid, or other third party. I understand that neither Vibrational Vitality nor healthcare providers in the Vibrational Vitality network will complete or sign any insurance papers.
  22. I authorize Vibrational Vitality and the healthcare providers in the Vibrational Vitality network to perform the procedures necessary and advisable to maintain my medical health and monitor my treatment, including, but not limited to, obtaining my medical history and treatment information, conducting physical examinations, ordering or conducting diagnostic testing (e.g. genetic, gut and blood labs), developing treatment plans and discussing them with other treating physicians and administering medications. I agree to cooperate with Vibrational Vitality in managing my treatment, including presenting myself for follow-up evaluations and testing.
  23. I understand and agree that the healthcare providers in the Vibrational Vitality network are not my primary care providers and are not intended to replace my current primary care provider. I understand that my Vibrational Vitality supervised treatments will be in conjunction with the care provided to me by my primary care physician. I agree to keep the healthcare providers in the Vibrational Vitality network and my primary care physician informed of any changes in my health or adverse reactions to any medications throughout my treatment.  www.vibrationalvitality.com | (904) 385-0497
  24. I understand and agree that medicine is not an exact science, and therefore, any medical treatment offered by Vibrational Vitality and its healthcare provider network is not accompanied by any claims, guarantees, promises, or warranties.
  25. I guarantee that all my responses are complete, truthful, and accurate. I understand that medications, treatments, or therapies prescribed or administered by Vibrational Vitality System may be subject to substance rules of professional sports organizations and anti-doping agencies. I take sole responsibility for ensuring compliance with substance rules, recognizing the potential consequences of violations, and releasing Vibrational Vitality LLC, from liability related to prescribed substances. Additionally, I assume responsibility for confirming the legality of treatments and agree to indemnify and hold harmless Vibrational Vitality for any non-compliance or violation of this form.
  26. I understand that any data I provide to Vibrational Vitality or its provider network throughout my customer journey is subject to Vibrational Vitality’s Privacy Policy.
  27. All tests are confidential and may be disclosed only to you, your parent/guardian, Vibrational Vitality’s providers, and other Vibrational Vitality personnel, and any healthcare provider you approve in writing or required by law. The sample will be destroyed at the end of the testing process or not more than 60 days after the sample was taken, unless I expressly authorize a longer period of retention in writing.
  28. By signing below, I hereby expressly consent to allow Vibrational Vitality to use and process my data (a) for the purposes in this Form and (b) to allow Vibrational Vitality to contact me through the e-mail and/or phone number (including by automated SMS texts) I provided for care coordination and promotional and marketing purposes. I hereby consent to allow Vibrational Vitality to de-identify or anonymize my data and use or disclose the same to the extent not prohibited by applicable law.

Mammogram and Pap Smear Waivers:

If applicable, I, the customer, understand and acknowledge:
I am aware that regular, comprehensive screening for breast cancer, including screening mammography, is medically indicated for my age group. I understand I should follow the recommended guidelines established by the US Preventive Services Task Force.
I am aware that PAP and/or Transvaginal Ultrasound are the best single method for the detection of early ovarian, endometrial, and/or cervical cancer. I understand I should follow the recommended guidelines established by the US Preventive Services Task Force.

State Specific Disclosures

FLORIDA, MASSACHUSETTS, MINNESOTA, NEW HAMPSHIRE, TEXAS, AND VERMONT RESIDENTS: I understand that my consent allows Vibrational Vitality LLC the use my de-identified genetic information for research and/or education. If I do not give permission, my de-identified genetic information may still be used to develop new tests and to improve or confirm the quality of existing tests, including sharing de-identified data with public databases. Aggregate information that includes my genetic information (e.g., summary information like a total number of customers tested with a particular variant) may still be shared.
MINNESOTA RESIDENTS: I understand that my consent to disclose genetic information as described in this form is valid for one year from the date, I sign this Form.

WYOMING RESIDENTS: I understand that I have the right to inspect, correct, and obtain my genetic information and request destruction of my genetic information under certain circumstances by Wyoming Statutes § 35-32-103. However, Vibrational Vitality LLC may deny my request to destroy my genetic information under certain circumstances, including if retaining my information is necessary for one of the purposes described in this Form.

Customer Signature_______________________              Date______________________