Schedule Appointment with Dexafit Las Vegas

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Item	Quantity	Total
Annual DELUXE Membership, $625 total savings! (Billed annually)	x $399.00	$399.00 per year
Total: $399.00	Coupon:

TERMS AND CONDITIONS

I consent to allow Foreshadow Industries LLC, DBA DexaFit Las Vegas, to use their DXA scanner to perform a body composition and/or bone densitometry scan, with full awareness that the technology uses low-dosage x-rays. I understand that I may request to see the certification through the State of Nevada verifying the DXA Scanner owned if I wish.

RECORDS REVIEW FOR RESEARCH

I also authorize Foreshadow Industries LLC, DBA DexaFit Las Vegas, to review my records to determine my body scan’s qualifications for approved clinical studies and to contact me if I have potential as a research candidate. No records are ever provided to other persons for research purposes, except by specific written approval from me.

FINANCIAL RESPONSIBILITY

I accept financial responsibility for all charges for services provided to me and/or my family members, and that police charges will be filed against me should I fail to pay after any services are rendered.

WAIVER AND AGREEMENT

1. I do hereby release all representatives of Foreshadow Industries LLC, DBA DexaFit Las Vegas that are acting upon their behalf from any responsibility or liability for any injury or damage to myself, including those caused by the negligent act or omission of any of those mentioned or others acting on their behalf or in any way arising out of or connected with my participation in services, activities, or programs of Foreshadow Industries LLC, DBA DexaFit Las Vegas.

2. I am voluntarily participating in the Foreshadow Industries LLC, DBA DexaFit Las Vegas’s, DXA scanner and/or other services, including RMR and VO2 Metabolic Analysis. I hereby agree to expressly assume any and all risks of injury and death resulting from participation in the aforementioned services.

3. I further hereby 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 Foreshadow Industries LLC, DBA DexaFit Las Vegas. I acknowledge that I have permission to participate or that I have decided to participate in these services without the approval of my physician and do hereby assume all responsibility for my participation.

4. I take full responsibility for any action taken by me after my visit to Foreshadow Industries LLC, DBA DexaFit Las Vegas. I will not hold any of their representatives responsible or liable for any adverse effects or complications arising from the services or opinions offered.

5. Confidentiality. The information based on the observations made during the DXA scan, VO2, or RMR analysis, and subsequent report is treated as privileged and confidential. However, it may be used for statistical or scientific purpose with your right to privacy retained.

6. I understand that Foreshadow Industries LLC, DBA DexaFit Las Vegas 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.

7. I agree that I may be charged a deposit to book this service. I understand that if I do not show up for the scheduled appointment, the deposit will be forfeited to Foreshadow Industries LLC, DBA DexaFit Las Vegas, for time slot utilized. I understand that if I have to change my appointment, I must do so no later than 48 hours before booking, or I will forfeit the deposit.

8. I agree that I have read, and will comply with, the pre-appointment checklist for my appointment. If I arrive at my appointment and am unable to participate in the test scheduled due to failure to comply with the checklist instructions, I will be able to reschedule the test, but will be charged the cost of the deposit.

CLIENT HIPAA CONSENT FORM

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize 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 Las Vegas’ 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 you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

AUTHORIZATION FOR RELEASE OF HEALTH INFORMATION

I hereby authorize Foreshadow Industries LLC, DBA DexaFit Las Vegas to forward the health and fitness information resulting from their services to me or any parties authorized by me by means of email, fax, mail, or through the private login page on the Dexa Fit LLC website. I also understand that this Authorization is subject to revocation/withdrawal by me at any time in writing to DexaFit, LLC, except to the extent that the action has already been taken to release this information. This Authorization shall remain value unless revoked. DexaFit, LLC will not forward my health and fitness information if I do not consent to this Authorization.