Intake Questionnaire

1. Payment

I am responsible for all charges for my visits, labs, and medications, including anything my insurance does not pay. This covers any medical service, visit, exam, physical, lab test, or other diagnostic testing ordered by my provider or my provider’s staff. I agree to pay in full whenever payment is required. I will keep a valid card on file, and Amazing Meds may run it electronically for my balance. Balances 90 days past due may go to collections, and I may not be seen for more services until my balance is paid in full. Fees may apply for record copies and for forms my provider fills out. Orders process after payment clears; allow 12 to 15 business days.

2. Insurance

Amazing Meds bills insurance for visits and labs when my plan allows. I am responsible for confirming my plan is in network and for keeping my insurance and contact information current. My plan decides my copay and deductible. Medications and peptides are not covered or reimbursable, and some visits and labs may not be covered.

3. Appointments

I will cancel or reschedule at least 24 hours ahead. A late cancellation, a no-show, or not finishing required labs before a visit may result in a $45 fee that insurance does not cover. If I am 15 or more minutes late, my visit may be rescheduled. Reminders are a courtesy. Repeated missed visits may end my care with the practice.

4. Telehealth

My visits happen by live video or audio. During a telehealth visit, my medical history, exams, and tests will be discussed by video or audio, and a virtual exam may take place. Other medical professionals, such as medical assistants or scribes, may be present to assist the provider, and photographs may be taken of me during the visit. In an emergency, the telehealth provider is responsible for directing me to emergency medical services, such as an emergency room. The telehealth provider may also discuss my care with my local provider, if applicable. The telehealth provider’s responsibility ends when the telehealth connection ends.

Telehealth has limits. Connections can fail, the information may not be enough for a medical decision, and no technology is fully secure. I can decline or stop telehealth at any time without losing my right to future care.

5. Contact

Amazing Meds may contact me about my care, appointments, and billing by text, voicemail, and email at the contacts on file. Messages may include health or billing details. Text and email are not encrypted and could be seen by others. I can opt out of any of these at any time by replying STOP or telling the office.

NOTE: If your insurance doesn’t pay for your services below, you may have to pay. Insurance providers do not pay for everything, even some care that you or your healthcare provider have good reason to think you need. We expect your insurance may not pay for some of your services. The portion(s) of patient cost for services that insurance does NOT cover will become the PATIENT’S responsibility.

Service: Office visit, Labs, and/or Medications/peptides
Reason insurance may not pay: Not medically necessary / Not covered by insurance

Estimated costs:

• Office visit: $140 – $185
• Labs: $189 – $510
• Medications/Peptides: $100 – $3,000

WHAT YOU NEED TO DO NOW:

• Read this notice, so you can make an informed decision about your care.
• Ask us any questions that you may have after you finish reading.
• Choose an option below about whether to receive the laboratory testing listed above.

At Amazing Meds, we are dedicated to providing high-quality and timely care to all patients. To help us maintain efficient scheduling and care delivery, we have implemented the following Late Arrival, Cancellation, and No-Show Policy. Please read and acknowledge the following guidelines:

1. We kindly request at least 24 hours’ notice if you need to cancel or reschedule your appointment. This allows us to offer your time slot to another patient.
2. Late cancellations (less than 24 hours’ notice), missed appointments without notice (“No-Call” / “No-Show”), or failure to attend your appointment may result in a $45 fee.
3. If required lab work is not completed prior to your appointment, your visit may need to be rescheduled, and the $45 fee may still apply.
4. This fee is not covered by insurance and will be your responsibility.
5. If you arrive 15 minutes or more after your scheduled appointment time, your appointment may be cancelled and rescheduled.
6. As a courtesy, we provide reminder calls or messages 1–2 days before your appointment. However, not receiving a reminder does not exempt you from this policy.
7. Repeated violations of this policy may result in termination of the physician-patient relationship. If you have any questions about this policy, please contact our office—we’re happy to help clarify.

Please acknowledge below to confirm you have read, understand, and agree to the terms of the Late Arrival, Cancellation, and No-Show Policy. A copy will be provided to you.

7. Care between visits

I agree to Chronic Care Management or Principal Care Management when my provider finds it appropriate.

This is 20 or more minutes a month of care coordination, medication management, and access to clinical staff. It may include check-ins, depression and anxiety screening, and home monitoring devices. It is billed to my insurance, and I may owe a copay. Only one practice can bill this per month, and I choose Amazing Meds. I can stop anytime by emailing billing@amazing-meds.com.

8. No refunds

Amazing Meds reserves the right to have a NO RETURN and NO REFUND policy. All medication orders are final once approved and processed. Under pharmacy regulations, compounded medications cannot be returned or reused once packaged for a specific patient.

No refund will be issued for change of mind, a change in treatment, or stopping treatment for any reason, including personal preference, cost, another provider’s advice, or choosing a different health route. No refund will be issued for dissatisfaction with dosing or results, since therapy is individualized and can take time to show benefits. No refund will be issued for missed delivery, an incorrect address, failure to pick up from a carrier facility such as FedEx or UPS, or delays caused by shipping carriers or compounding pharmacies. Medication not used or stored according to instructions is not eligible for a refund. A pharmacy substitution with an equivalent formulation is medically appropriate and is not grounds for a refund.