1. Consent to Medical Care

Pursuant to Florida Statutes § 766.103 ("Florida Medical Consent Law"), I voluntarily consent to receive medical care and treatment from PharmXHealthOne and its licensed providers, including physicians, nurse practitioners, physician assistants, and other authorized personnel.

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I understand and agree that:

• No non-emergency treatment will be provided without my informed consent.

• I may withdraw consent at any time.

• No guarantees are made regarding results of any treatment or service.

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The services offered include, but are not limited to:

• General and urgent care

• IV nutrient therapy

• Hormone replacement therapy (HRT)

• Peptide therapy and regenerative medicine

• Aesthetic/cosmetic services

• Diagnostic testing and lab analysis

 

I confirm that I have been informed of the risks, benefits, and alternatives in accordance with Fla. Stat. § 766.103(3), and that I have had the opportunity to ask questions.

 

2. Consent to Telehealth Services

In accordance with Florida Statutes § 456.47, I consent to receiving care through telehealth technology, including real-time audio and video interactions.

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I acknowledge:

• There are limitations to telehealth, including potential miscommunication or incomplete assessments.

• I am responsible for ensuring my environment is private and secure during sessions.

• Despite efforts to secure data, internet-based communication poses minimal risks beyond PharmXHealthOne’s control.

 

I understand that telehealth is not appropriate for all medical conditions, and in-person follow-up may be necessary.

 

3. Customized & Compounded Therapies Disclosure

Certain treatments, such as compounded medications, peptides, and off-label prescriptions, may not be reviewed or approved by the FDA.

Pursuant to Fla. Stat. § 499.003(11) and related Florida Pharmacy Practice Acts, I acknowledge and accept:

• These therapies are prescribed based on individual medical judgment.

• I voluntarily assume any associated risks.

• PharmXHealthOne uses licensed compounding pharmacies that comply with Florida law.

 

4. Infectious Disease Acknowledgment

In accordance with Fla. Stat. § 381.00315, I acknowledge and accept the risk of exposure to infectious diseases, including COVID-19, as a result of receiving medical care in-person or inviting providers into my home or workplace.

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I agree to notify the clinic immediately if I or anyone I’ve been in contact with shows symptoms of illness.

 

5. Financial Agreement & Payment Responsibility

Pursuant to Fla. Stat. § 559.72, I agree to:

• Pay in full for all services rendered by PharmXHealthOne, whether received in-person or online at www.pharmxhealthone.com.

• Make payment at the time of service or within 7 days of receiving diagnostic results or invoices.

• Pay any collections, legal, or administrative fees incurred in the recovery of unpaid balances.

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Non-Refundable Products and Services

In accordance with Fla. Admin. Code R. 64B16-27.1001, and due to the customized nature of prescriptions:

• All sales are final and non-refundable, including prescription medications, compounded products, peptides, supplements, labs, and wellness services.

• Refunds will not be issued under any circumstance unless required by law.

 

Recurring Subscription Policy

Monthly subscriptions auto-renew on a recurring billing date. To cancel, I must notify PharmXHealthOne in writing at least 72 hours prior to the next billing cycle via email to: health@pharmxhealthone.com. Once billed, subscription payments are non-refundable.

 

6. Mediation & Binding Arbitration Agreement

Pursuant to Fla. Stat. § 766.207 – 766.212, I agree that all disputes, including but not limited to those related to services, medical malpractice, billing, or outcomes, shall be resolved through:

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a. Mediation

As a first step, all disputes will be submitted to voluntary mediation in Palm Beach County, Florida, through a neutral third-party mediator from JAMS or AAA. Each party will bear its own legal fees and split mediation costs equally.

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b. Arbitration

If mediation fails, binding arbitration shall follow under Fla. Stat. § 766.207 and Federal Arbitration Act (9 U.S.C. §§ 1–16). Arbitration shall take place in West Palm Beach, Florida. The arbitrator will render a final, binding decision. I understand:

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• I am waiving my right to a jury or court trial.

• The decision cannot be appealed except as allowed by statute.

• The arbitrator may award reasonable attorney’s fees and costs to the prevailing party.

• Punitive damages are not permitted.

 

7. Governing Law

This agreement shall be governed by the laws of the State of Florida, specifically:

• Title XLV, Chapter 766 (Medical Malpractice & Related Matters)

• Title XXXII, Chapter 456 (Health Professions and Occupations: General Provisions)

• Florida Arbitration Code, Chapter 682, where applicable.

Any legal disputes not subject to arbitration shall be adjudicated exclusively in Palm Beach County, Florida courts.

 

8. Severability Clause

In accordance with Fla. Stat. § 682.14, if any provision of this agreement is held invalid or unenforceable, the remainder shall remain in full force and effect. Invalid provisions will be enforced to the maximum extent permitted by law.

 

9. Acknowledgment & Electronic Signature

By signing this document or checking the box during online checkout at www.pharmxhealthone.com, I acknowledge and agree that:

• I have read, understood, and voluntarily agree to the terms stated herein.

• I may request a physical or digital copy of this agreement at any time.

• My agreement remains in effect until revoked in writing, except for the financial, legal, and arbitration provisions, which survive indefinitely.

 

Patient Name: ____________________________

 

Signature: ________________________________

 

Date: _____________________