Terms and Conditions
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby grant consent to DexaFit Jacksonville and/or DexaFit, Inc. for the utilization of their DXA scanner to perform body composition and/or bone densitometry scans, acknowledging the use of low-dose x-rays in the technology.
RECORDS REVIEW FOR RESEARCH
I also authorize DexaFit Jacksonville and/or DexaFit, Inc. to utilize or review my de-identified records for research purposes and to evaluate my eligibility for approved clinical studies, permitting them to contact me if I meet the criteria as a research candidate.
ADDITIONAL SERVICES AND TESTING
In conjunction with DXA scans, DexaFit Jacksonville and/or DexaFit, Inc. offers a comprehensive suite of services designed to enhance your wellness journey
Red Light Therapy: I acknowledge the provision of red light therapy services by DexaFit Jacksonville and/or DexaFit, Inc. This therapy exposes individuals to low-level wavelengths of light, offering potential holistic benefits. Recognizing the inherent risks associated with any procedure, I am aware that DexaFit Jacksonville and/or DexaFit, Inc. is absolved of any liability arising from the practice of red light therapy. Furthermore, I understand that DexaFit is not liable for any damage caused or inaccuracies in the reports resulting from red light therapy sessions.
PHY Postural Body Scans: As part of its service offerings, DexaFit Jacksonville and/or DexaFit, Inc. provides PHY postural body scans, a cutting-edge technology capturing three-dimensional images for precise body alignment analysis. I hereby provide informed consent for the application of this technology in assessing my body alignment. Additionally, I acknowledge that DexaFit is not liable for any inaccuracies in the PHY postural scan reports or any consequences arising from following advice based on these reports.
RMR Testing (Resting Metabolic Rate): DexaFit Jacksonville and/or DexaFit, Inc. introduces Resting Metabolic Rate testing services, a method for determining the caloric requirements of the body at rest. I willingly provide consent for the administration of this test, recognizing its role in tailoring wellness strategies. I acknowledge that DexaFit is not liable for any inaccuracies in the RMR test reports or any consequences resulting from following advice based on these reports.
Nutrition Counseling: DexaFit Jacksonville and/or DexaFit, Inc. provides nutrition counseling services as part of its comprehensive wellness offerings. This service is designed to offer guidance and support for nutritional goals. It is expressly understood and agreed that DexaFit Jacksonville and/or DexaFit, Inc. makes no guarantees regarding specific results from nutrition counseling.
Achieving nutritional objectives is contingent upon the client's dedication and adherence to recommendations. While DexaFit Jacksonville and/or DexaFit, Inc. are committed to delivering professional guidance, individual outcomes may vary based on personal choices and other contributing factors.
It is explicitly acknowledged that DexaFit Jacksonville and/or DexaFit, Inc. bears no liability for outcomes or consequences resulting from nutrition counseling sessions. The client assumes full responsibility for achieving desired nutritional outcomes.
The client expressly waives any right to bring legal action against DexaFit Jacksonville and/or DexaFit, Inc. for poor advice or to hold them legally responsible for any unfavorable outcome arising from nutrition counseling services.
By engaging in nutrition counseling services, the client affirms a comprehensive understanding of the nature of this offering and unconditionally accepts the stipulated terms.
In appreciation of the comprehensive services offered by DexaFit Jacksonville and/or DexaFit, Inc., I embrace these offerings with confidence in the commitment to client well-being. I understand the nature of each service and acknowledge the terms outlined herein.
FINANCIAL RESPONSIBILITY:
I hereby acknowledge and assume full financial responsibility for all charges related to the services provided to myself, my family members, and/or my responsible parties at DexaFit Jacksonville. I understand and agree that all payments are non-refundable within 24-hours of appointment, and I explicitly waive any right to dispute transactions. Group Packages and are non refundable after first use, all other restrictions apply.
In the event of a cancellation within a 24-hour period preceding the scheduled appointment, I acknowledge that no refunds will be issued. Additionally, I commit to paying a $75 rescheduling fee for any changes made within a 24-hour timeframe from the scheduled appointment. There will be no refund issues for no-show appointments.
Furthermore, I recognize that should I choose to reschedule within 24 hours of the appointment and subsequently cancel, I am obligated to pay the complete value of the service along with an additional rebooking fee.
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WAIVER AND AGREEMENT
I release all representatives of DexaFit Jacksonville and/or DexaFit, Inc. from any responsibility or liability for injury or damage to myself, including those caused by the negligent acts or omissions of those mentioned or others acting on their behalf, arising out of or connected with my participation in services, activities, or programs of DexaFit Jacksonville and/or DexaFit, Inc.
I am voluntarily participating in the DexaFit Jacksonville and/or DexaFit, Inc DXA scan service and/or other services, including PHY scans, RMR and VO2max Metabolic Analysis, Red Light Therapy, Training Programs, and nutritional/meal planning consultation, and all other services performed by DexaFit Jacksonville. I expressly assume all risks of injury and death resulting from participation in the aforementioned services.
I declare myself to be physically sound and suffering from no condition, impairment, disease, infirmity, or other illness that disqualifies me from receiving a DXA scan from DexaFit Jacksonville and/or DexaFit, Inc. I acknowledge that I have permission to participate or have decided to participate in these services without the approval of my physician, assuming all responsibility for my participation. I also certify that I am not pregnant or trying to become pregnant.
I take full responsibility for any action taken by me after my visit to DexaFit Jacksonville and/or DexaFit, Inc. I do not hold any representatives of DexaFit Jacksonville or DexaFit, Inc responsible or liable for any adverse effects or complications arising from the services or opinions offered by them.
Confidentiality: Information based on the observations made during the DXA scan, VO2max, or RMR analysis, and subsequent reports are treated as privileged and confidential. However, it may be used for statistical or scientific purposes while retaining your right to privacy.
I understand that DexaFit Jacksonville and/or DexaFit, Inc does not diagnose or interpret the DXA results, and that any further review or analysis of the report is between the individual and their primary care physician.
CLIENT HIPAA CONSENT FORM
I understand that I have certain rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). By signing this consent, I authorize DexaFit Jacksonville and/or DexaFit, Inc to use and disclose my protected health information to carry out:
Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
Obtaining payment from third-party payers (e.g. my insurance company)
The day-to-day operations of DexaFit Jacksonville practice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that DexaFit is not required to agree to these requested restrictions. If agreed, DexaFit is bound to comply with these restrictions.
I may revoke this consent in writing at any time, but any use or disclosure before the date of revocation is not affected.
AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION
I authorize DexaFit Jacksonville and/or DexaFit, Inc to forward the health and fitness information resulting from their services to me or any parties authorized by me through email, fax, mail, or the private login page on the DexaFit website. This Authorization is subject to revocation/withdrawal in writing by me to DexaFit Jacksonville, except for actions already taken to release this information. This Authorization shall remain valid unless revoked, and DexaFit Jacksonville and/or DexaFit, Inc will not forward my health and fitness information if I do not consent to this Authorization.
I attest that I am NOT pregnant and 350 pounds and have read and agreed to the above, consenting to participate in the services rendered by Dexafit Jacksonville.
Consent Form for VO2max:
Purpose and Explanation for the Test:
You will perform a graded exercise test on a motor-driven treadmill or stationary bike. The exercise intensity will begin at a low level and advance in stages, depending on your fitness level. The test may be stopped at any time due to signs of fatigue, changes in heart rate or blood pressure, or any symptoms you may experience. You may stop the test at any time due to feelings of fatigue or discomfort.
Attendant Risks and Discomforts:
As with any exercise, there exists the possibility of certain changes occurring during the test, including abnormal blood pressure, fainting, irregular, fast, or slow heart rhythm, and, in rare instances, heart attack, stroke, or death. Please note that there will NOT be a physician present on-site.
You and your own Doctor should evaluate the information you possess about your health status or previous experience with exercise-related or heart-related symptoms (such as shortness of breath with low-level physical activity, pain, pressure, tightness, or heaviness in the chest, neck, jaw, back, and/or arms) that may affect the safety of your test. Your prompt reporting of these and any other unusual feelings during the test is of great importance. You are responsible for consulting with your own doctors before taking the test.
Inquiries
Any questions about the procedures used in the exercise test or the results of your test are encouraged. If you have any concerns or questions, feel free to ask via email at Jacksonville@dexafit.com prior to the test.
I hereby consent to engage in an exercise test to determine my exercise capacity. My permission to perform this test is given voluntarily. I understand that I may stop the test at any point if I so desire. I have read this form and understand the test procedures I will perform and the attendant risks and discomforts. I understand that there will NOT be a supervising physician onsite. Knowing these risks and discomforts, and having had an opportunity to ask questions that have been answered, I consent to participate in the test.
Referral Program
The referral program applies only to new client bookings.
Referral codes must be entered at the time of booking to be valid.
Clients cannot cancel an existing appointment and rebook using a referral code. Doing so will result in the forfeiture of the referral prize, and no refund will be provided for the initial appointment.
The referral prize (complimentary DexaFit Core Test) is awarded only after successfully referring 5 individuals who complete their bookings.
If a client cancels their appointment, they forfeit the referral prize, even if the required referrals have been achieved.
Referral codes are unique to each client and are based on their phone number without punctuation.
DexaFit Jacksonville reserves the right to modify or terminate the referral program at any time.
The referral prize has no cash value and is non-transferable.
DexaFit Jacksonville is not responsible for any technical issues or delays in the referral tracking system.
Limit 4 free core test per year
Other terms and conditions may apply. Please contact DexaFit Jacksonville for any further clarification.
By participating in the DexaFit Jacksonville Referral Program, clients agree to abide by these terms and conditions. DexaFit Jacksonville reserves the right to interpret these rules and make decisions at its discretion.