New Medications—may initially cause drowsiness/sedation/dizziness, nausea, vomiting, constipation or diarrhea and dry mouth. Try to continue medication for at least 3-5 days to allow your body time to adjust to the new medication. If symptoms are intolerable, notify office and discontinue use.
• Put un-used medications in a safe place and inform us. Do not flush, throw away, give to someone else for use, or save.
• Controlled Substances/Opioid Medications--these are strictly regulated by state and federal law. If you receive this type of medication, you will need to be seen at least once every 28 days-- whether at an office visit, procedure or diagnostic evaluation.

For Your Safety:
• Your physicians and practitioners of Age Well LLC will obtain, provide and discuss information regarding medical treatment, diagnostic tests, medication, and medical conditions in accordance with HIPAA guidelines—see HIPPA Policy.
• You may receive pain medication prescribed by physicians through Age Well Dr only. *Inform Emergency Room, surgeons or other physicians that you are under the care of medications taken by our clinic and they may contact Age Well Dr for recommendations.
• Do NOT break, crush, or chew any of your medication unless instructed to do so.
• Use the same pharmacy to ensure your medications are in stock, maintain consistent medication history and decrease discrepancies.

* Withdrawal medication may be provided if needed for lost, stolen, self-increased or any other count discrepancies. Early refills will not be provided nor any refunds for any medications.

Consent for the Use and Disclosure of Protected Health Information

By signing below, you consent to the use and disclosure of your protected health information by Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC, our staff, and our business associated/s for treatment, payment and health care operations. For a more detailed description of uses and disclosures for these purposes, please review our Notice of Information Practices (“Notice”). You have the right to review our Notice prior to signing this consent. The terms of this Notice may change. If the terms do change, you may obtain a revised version by simply contacting Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC and requesting a revised Notice. We will also post any revised notice in this facility. You have the right to request that we restrict our uses or disclosures of your protected health information which we are otherwise permitted to make for treatment, payment and health care operations, although we are not required to agree to these restrictions. However, if we agree to further restrictions, they are binding on us. Finally, you have the right to revoke the consent in writing, except to the extent that we have taken action in reliance on it.

RELEASE AND WAIVER OF LIABILITY

I have read and understand this waiver and have been fully informed of all Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC Medical Spa terms and conditions as well as benefits and limitations. I certify that I have disclosed all medical conditions that might affect my treatments as well as previous products and services used and their side effects, if any. Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC disclaims liability for any loss, injury, claim or damage related to your use of its products and services, including without limitation, those resulting from errors or omissions, a site or application being down, data loss, and unsatisfactory aesthetic outcomes. Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC. will not be liable to you for any indirect, incidental, consequential, reliance or special damages, including without limitation damages arising from any court action or legal dispute. In no event shall the aggregate liability of Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC, whether in contract, warranty, tort (including negligence, whether active, passive or imputed), product liability, strict liability or other theory, arising out of or relating to the use of Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC’s products or services, exceed any compensation paid by you for treatment by Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC during the three months prior to the date of any claim. I release my providers from any injury or complication resulting from undiagnosed medical conditions present during my treatment. I assume all responsibility for updating changes in physical and mental condition.

INDEMNIFICATION

You will indemnify and hold harmless Dr. Zamil Islam or Age Well LLC and its officers, agents, employees, representatives, and assigns from any costs, damages, expenses, and liability caused by your use of any of Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC’s products and service.
I have read and understand this waiver and have been fully informed of all Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC terms and conditions as well as benefits and limitations. I certify that I have disclosed all medical conditions that might affect my treatments as well as previous products and services used and their side effects, if any. Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC disclaims liability for any loss, injury, claim or damage related to your use of its products and services, including without limitation, those resulting from errors or omissions, a site or application being down, data loss, and unsatisfactory aesthetic outcomes. Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC will not be liable to you for any indirect, incidental, consequential, reliance or special damages, including without limitation damages arising from any court action or legal dispute. In no event shall the aggregate liability of Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC, whether in contract, warranty, tort (including negligence, whether active, passive or imputed), product liability, strict liability or other theory, arising out of or relating to the use of Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC’s products or services, exceed any compensation paid by you for treatment by Dr. Zamil Islam, Age Well LLC or Age Well Dr Houston PLLC during the three months prior to the date of any claim. I release my providers from any injury or complication resulting from undiagnosed medical conditions present during my treatment. I assume all responsibility for updating changes in physical and mental condition.

CONSENT FOR CARE AND TREATMENT

I understand my right to participate in my treatment process. I am mentally competent and do hereby consent to necessary examination, procedures, and/or treatments prescribed by my physician, his assistants or designees as is necessary in his/her judgment.