Healthcare Immunity Gummies Form

Healthcare Immunity Gummies Form

This form documents patient information, medical screening, informed consent, and authorization for the administration or distribution of immunity-promoting gummy supplements (hereafter "Product"). The Product is a dietary supplement. The patient acknowledges receipt of information about ingredients, dosing, potential adverse reactions, and contraindications and consents to receive the Product under the terms below.

Patient Information

Patient Name:

Female   Male   Other/Prefer not to say

Insurance Information (Optional)

Medical History & Screening

Are you pregnant or breastfeeding?  Yes   No

Do you have a weakened immune system or are you on immunosuppressive therapy?  Yes   No

Product Information and Risks

Product Name/Brand:

Active ingredients and typical dose per gummy (as disclosed to patient):

Recommended administration (number per dosing interval):

Known or potential risks, adverse effects, and interactions include but are not limited to: gastrointestinal upset, allergic reaction (hives, swelling, anaphylaxis), headache, changes in blood sugar, interaction with prescription medications, and unpredictable effects in pregnancy or lactation. The patient acknowledges these risks were explained and had opportunity to ask questions prior to administration.

I acknowledge that the Product is a dietary supplement and not a prescription medication, that results are not guaranteed, and that no promises of cure or prevention of disease have been made by the provider.

Patient attests that they have received and reviewed the ingredient list and labeling: I have received the label and ingredient list

Contraindications Screening (select as applicable)

History of severe allergic reaction (anaphylaxis) to gummy ingredients or related substances:  Yes   No

Concurrent use of anticoagulant, immunosuppressant, or other interacting medications:  Yes   No

Recent hospitalization or severe illness within past 30 days:  Yes   No

Authorization, Release, and Certification

By signing below, I certify that the medical information I have provided is complete and accurate to the best of my knowledge. I authorize the administering clinician or authorized staff to provide the Product as described above. I acknowledge that no guarantee has been made regarding the therapeutic outcome.

I voluntarily assume the risk of any adverse effects and release and hold harmless the administering provider, clinic, its agents, and employees from claims, liability, or costs arising from the administration of the Product except for acts of gross negligence or willful misconduct. This release does not apply to statutory claims that cannot be waived by agreement.

In the event of a serious adverse reaction, I authorize the provider to seek or secure emergency medical treatment on my behalf and to share relevant medical information with emergency responders and treating facilities for the purpose of treatment.

HIPAA and privacy: I acknowledge that the clinic may use and disclose my protected health information for treatment, payment, and healthcare operations as necessary to provide the Product and to respond to adverse events. I consent to the use of my information for these purposes and understand I may request restrictions in writing.

I understand that I may revoke this authorization at any time by submitting a written revocation to the clinic, except to the extent that action has already been taken in reliance on this authorization. Revocation will not affect disclosures made prior to receipt of revocation.

Supplement Administration Record (to be completed by staff)

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