Patient Consent Form

Please read and fill out the form below.

Evolve Healthcare Informed Consent to Treatment
Dr. Igor Gary Shlifer DO
NPI 1295174860

This informed consent to treatment provides important information regarding the services being provided and should be carefully reviewed before signing below. It is designed to inform you about Dr. Shlifer’s practices, to ensure that you understand your patient rights and the professional relationship between doctor and patient, and to obtain your informed consent in this relationship. When you sign this document, it will authorize Dr. Shlifer to initiate care and commence services in accordance with this document. Please ask any questions you have regarding this document and Dr. Shlifer’s services before signing this document. 

By signing below, I acknowledge and agree to the following:

I hereby request and consent to receive medical care, treatment, procedures, and/or services as more fully outlined below, by Dr. Shlifer.

Medical Treatments/Services: I understand that the methods of treatment/services employed by Dr. Shlifer may include but are not limited to: nutritional counseling, COVID-19 testing, any laboratory testing, STD screening, nutritional supplements, prescription medications, IV therapy, imaging studies, mind-body medicine, and stress management. 

I understand that all treatments, whether those listed above or any others, will be discussed with me before treatment begins and I am encouraged to ask questions. 

Potential Risks of Medical Treatments/Services: I am aware that all existing methods of diagnosis and treatment, including medical treatments/services, pose some level of risk. Within the general healthcare setting, the possible outcomes of these practices by a doctor range from minor to fatal. I understand that potential risks of medical treatment/services include, but are not limited to: allergic reactions from prescribed medications/supplements which may be severe such as anaphylaxis, cardiac arrest, and death; unpleasant side effects from medications/supplements; inconvenience of lifestyle changes; aggravation of present conditions; injuries such as pain, discomfort, bruising, and discoloration from venipuncture or from intravenous procedures; and pain and discomfort from any nasal swabbing for COVID-19 testing. 

I am aware that unforeseeable complications could occur, and that while Dr. Shlifer and his medical team will make every reasonable effort to screen for contraindications in my care,  I do not expect Dr. Shlifer and his medical team to be able to anticipate and explain all potential risks and complications, and I wish to rely on Dr. Shlifer to exercise judgment in recommending the medical treatments/services that he feels at the time, based on the facts then known, are in my best interest.

I understand that in order to treat my medical condition, Dr. Shlifer’s office must be contacted promptly if an adverse reaction or condition occurs while under his care.

In any event, if an emergency medical condition arises for any reason due to a medical treatment/service from Dr. Shlifer or for any other reason, I agree to seek treatment immediately from an emergency center or to call 911. 

I understand the above overview of Dr. Shlifer’s medical treatments/services and the potential risks of such treatment.

Complete Medical History: I understand that in order for Dr. Shlifer to accurately assess and treat my medical condition, I will have to disclose any pre-existing health conditions, medications, and supplements as well as keep Dr. Shlifer updated as to any changes. 

I have truthfully and accurately disclosed to Dr. Shlifer all personal medical history information including but not limited to: all of my medical conditions, my use of all medications, drugs, vitamins, and other supplements of any kind, and all known allergies to drugs or other substances or any past reactions.

I understand that failure to do so may negatively affect my treatment outcome and the safety of any treatments/services I may receive. I agree to keep Dr. Shlifer updated as to any changes or alterations in my medical profile and understand that there shall be no liability on Dr. Shlifer’s part should I fail to do so.

Patient Rights: I understand that I have the right to refuse any procedure or treatment prescribed by Dr. Shlifer. I understand that I have the right to discuss all medical treatments/services with my provider and have the right to seek alternate care if I refuse any treatments/services prescribed by Dr. Shlifer. I also understand that I have the right to request any and all of my medical records from Dr. Shlifer’s practice.

Billing Health Insurance: If billing through health insurance, I allow Evolve Healthcare to file for insurance benefits to compensate for the care I receive. I understand that Evolve Healthcare will have to send my medical information to my insurance company. I understand that I must compensate Dr. Shlifer for my share of the costs, such as a copay. I also understand that I must pay for the cost of these services if my insurance rejects the claim or I do not have insurance.