Today’s Date: _____ /______ / ______ Driver’s License. # _________________________ SS# _____- ______- ______

First and Last Name: _____________________________________________________________________________

Primary Reason for Today’s Visit: __________________________________________________________________

Sex: ___________ Date of Birth: _______/_______/_______ Age: ________

Mailing Address: __________________________________________________________________________________

City: ____________________________________________ State: ____________ Zip: __________________________

E-mail Address: __________________________________________________________________________________

Home: (______) _______-________ cell: (______) _______-_________ work: (_____) _______- __________________

Occupation: ________________________________ Employer: ____________________________________________

Spouse/Partner Name: ________________________________ Spouse/Partner Birth Date: _______/_______/ _______

Referral Information How did you hear about us? Please circle the referral type and specify in the space below.

Healthcare practitioner / Friend or Family / Website / Search Engine / Print Media / Mailer / Other

Please specify: ___________________________________________________________________________________

Payment must be made at the time of service. We do accept Aetna, Anthem Blue Cross, Blue Shield, Medicare and United PPO insurances for office visits. For other PPO insurances we can bill your insurance as an out of network provider.

Note: There is a 48 hour cancellation fee of $100.00 and the IV nurse cancellation fee of $50.00. Please be on time for your appointments.

Who is financially responsible for this bill?

Who may we contact in case of an emergency?

Name: ____________________________________________________ Tel __________________________________

If you are a minor (under 18) or dependent, please provide us with your guardian’s information:

Name of Guardian: _________________________________________ Tel: __________________________________

I understand and agree that, regardless of my insurance status, I am ultimately responsible for the balance of my account for any professional services rendered. I certify that the information above is correct and true to the best of my knowledge. I will notify the Health and Vitality Center of any changes in the status of the above information.

Signature: _______________________________________________ Date: __________________________________

Parent Signature (if minor) __________________________________ Date: __________________________________

Past Medical and Surgical History:

________________________________________________________________________________________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Social History: 1. Do you smoke? Yes or No How many per day? ___________________________________________________

2. Do you drink alcohol? Yes or No How much and how often? _________________________________________

3. Do you use any street drugs? Yes or No How much and how often? ___________________________________

4. Do you exercise? Yes or No How often? What type? _______________________________________________

5. Tell us about your diet: _______________________________________________________________________

Family History: Who of your blood relatives have or had any of the following problems and at what age? 1. Heart Attack/Coronary artery disease: __________________________________________________________

2. Sudden death at an early age: ________________________________________________________________

3. High Cholesterol: ___________________________________________________________________________

4. High Blood Pressure: ________________________________________________________________________

5. Stroke: ___________________________________________________________________________________

6. Diabetes: _________________________________________________________________________________

7. Cancer: o Yes o No

Who: _______________________________ Type: ________________________________________________

Allergies (Please list anything you are allergic to (medications, food, environmental, pets, etc.) 1. __________________________________________ 3. ________________________________________________

2. __________________________________________ 4. ________________________________________________

Medications and Dosage (Include Bioidentical Hormones): 1. __________________________________________ 4. ________________________________________________

2. __________________________________________ 5. ________________________________________________

3. __________________________________________ 6. ________________________________________________

Nutritional Supplements and Over the Counter Medications: 1. __________________________________________ 4. ________________________________________________

2. __________________________________________ 5. ________________________________________________

3. __________________________________________ 6. ________________________________________________

______________________________________________ _________________________________________ Patient Signature Date

______________________________________________ _________________________________________ Physician Signature Date

Review of Systems Do you have any of the following (please check each item that applies)

1 GENERAL

o Yes o No My health is generally good o Yes o No Drug or alcohol problem o Yes o No Recent weight gain or loss of 25 lbs o Yes o No Cancer: Past / Present Type: _______ 2 CARDIOVASCULAR

o Yes o No Shortness of breath (Other than with exercise or smoking)

o Yes o No Blood clots o Yes o No Heart disease o Yes o No Heart Murmur o Yes o No Do you take medication prior to dental work? o Yes o No Stroke 3 EYES

o Yes o No Eye problems (not related to needing or wearing glasses)

4 NEUROLOGIC

o Yes o No Seizure/Epilepsy o Yes o No Migraine headaches (diagnosed) o Yes o No Visual Changes o Yes o No Other severe headaches 5 EARS, NOSE, THROAT, MOUTH

o Yes o No Hearing problems o Yes o No Frequent nose bleeds (more than 1per month) o Yes o No Frequent sore throat (more than 1per month) o Yes o No Asthma Treatment: ______________________ o Yes o No Tuberculosis Treatment: __________________ o Yes o No Lung disease 7 GASTROINTESTINAL

o Yes o No Nausea/vomiting (not related to pregnancy) o Yes o No Abdominal pain (not related to menstrual cramps) o Yes o No Stomach/bowel problems o Yes o No Liver disease o Yes o No Gallbladder disease

8 ALLERGY / IMMUNOLOGIC

o Yes o No Hayfever o Yes o No Do you tale any allergy medications? If yes list: _______________________________________ o Yes o No Do you have any allergies to foods? o Yes o No History of Lupus or other Autoimmune diseases?

9 SKIN / BREAST

o Yes o No Acne o Yes o No Pain in your breast (not related to menses) o Yes o No Discharge from your nipples o Yes o No Mass / lump in your breast o Yes o No Breast disease / tumor / surgery 8 GENITAL / URINARY

o Yes o No Bladder / kidney problems o Yes o No Urinary pain o Yes o No Urinary frequency o Yes o No Losing or leaking urine o Yes o No Abnormal vaginal bleeding o Yes o No Pain with intercourse o Yes o No Recurrent vaginal infections o Yes o No Do you now have abnormal vaginal

discharge, itchy or odor o Yes o No Abnormalities of the uterus, ovaries, tubes,

or vagina o Yes o No History of uterine fibroids 8 PSYCHIATRIC

o Yes o No Depression o Yes o No Anxiety o Yes o No Seeing a therapist or psychiatrist o Yes o No Suicide attempt When: _____________

Counselling o Yes o No ___________ o Yes o No Feeling suicidal now o Yes o No Eating disorder When: _____________

Counselling o Yes o No ___________ 8 ENDOCRINOLOGY

o Yes o No Diabetes o Yes o No Thyroid problem o Yes o No Diabetes with pregnancy 8 HEMATOLOGY

o Yes o No Blood disorder / Hemophilia o Yes o No Anemia o Yes o No High cholesterol / triglycerides

Last tested: ______________________ Result: __________________________ Treatment o Yes o No

Patient signature: ___________________________

Patient name: ______________________________

Date:

INFORMED CONSENT FOR INTRAVENOUS THERAPY

I, __________________________________, acknowledge that my physician, Dr. Shiva Lalezar, has explained to me the

principles and practice of intravenous nutrient therapy. Specifically, this therapy includes intravenous administration of

vitamins, minerals, amino acids and other substances for general immune enhancement in chronic immune and

degenerative disorders, infections, and other medical conditions. Initial ________

I have been informed of the possible complications of this therapy, including inflammation of the vein, and the rare

possibility of an allergic reaction to the intravenous solutions. Allergic reactions may include rash, fever, respiratory or

cardiovascular problems. Serious allergic reactions are extremely unusual, and require discontinuation of the infusion and

emergency treatment if necessary. Fatigue or lightheadedness may also occur, and I have been told to eat before having

this treatment to reduce the likelihood of developing such symptoms. Initial ________

I have also been informed by my physician that DMPS or EDTA Chelation therapy may be used for cardiovascular

disease and/or heavy metal burden at my request and upon my physician’s recommendations. My physician has informed

me of other modes of therapy used for treatment of these conditions. I understand this procedure is investigational and

that a 6 hour urine toxicity screen is a non-standard and unconventional diagnostic test. Initial ________

My physician has also informed me that I may experience side effects such as discomfort at the injection site, fatigue,

muscle cramps and mineral imbalance, and that my physician will try to prevent them. Initial ________

I hereby acknowledge by this statement that I have been fully informed that some and perhaps all the medical services

provided at the Health & Vitality Center on or after this date by my physician are non-covered services and not considered

necessary under the Medicare program and/or other medical insurance. I realize that my insurance coverage including

Medicare will not pay for such non-covered services and that I will be personally responsible for payment to Dr. Shiva

Lalezar for all such non-covered services at the time services are rendered to me and a super bill will not be provided for

these non-covered services. Initial ________

I have read all the above and I fully understand what I am signing, and I hereby request and consent to receive these

treatments. Initial ________

__________________________________________ __________________________________________________

Signature of Patient or Responsible Person Date Signed

__________________________________________ __________________________________________________

Witness Date Signed

PHYSICIAN-PATIENT ARBITRATION AGREEMENT

Article 1: Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided on a court of law before a jury, and instead are accepting the use of arbitration.

Article 2: All Claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean the mother and the mother’s expected child or children. All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s partners, associates, association, corporation or partnership, and the employees, agents and estates of any if them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.

Article 3: Procedures and Applicable Law: A demand for arbitration must communicate in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of a judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, nit supplant, any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator. The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration. The parties agree that provisions of California law applicable to health care providers shall apply to disputes within this arbitration agreement, including, but not limited to, Code of Civil Procedure Section 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrations a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.

Article 4: General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in once proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.

Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days, or signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.

Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is Effective as of the date of first medical services.

Patient’s or Patient Representative’s Initials _________ If any provision if this arbitration agreement is held invalid of unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy. NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT. By: _____________________________ ______________ Patient’s or Patient Representative’s Signature Date By: ___________________________________ ________ By: ______________________________________________ Physician’s or Authorized Representative’s Signature (Date) Print Patient’s Name By: ___________________________________ By: ______________________________________________ Print or Stamp Name of Physician, If Representative, Print Name and Relationship to Patient) Medical Group or Association Name

A signed copy of this document is to be given to Patient. Original is to be files in Patient’s medical records.

Financial Responsibility I, _______________________________________, hereby certify that I am financially responsible for all the services

rendered by Dr. Shiva Lalezar, that are not covered by my insurance including: supplements, compounded medications in

the IV’s, patient share of cost, copayments, payments toward deductible, Hormone Age Management, HCG Weight Loss

Program, IV consults, and phone consults. I understand that I am financially responsible, and I agree to pay in full within

15 days of receiving the bill. Any returns or refunds are subject to a 10% fee based on the amount returned.

We require you to keep a credit card on file for no show fees. If you do not cancel 48 hours prior to your

scheduled appointment time, you will be charged $350 if new patient, $250 if follow up appointment, and $195 for phone

and IV consultations.

Credit Card Number _______________________________ Expiration ________________________________

CVC ____________________________________________ Zip Code ________________________________

Patient or Guardian Signature ________________________ Date ____________________________________

Witness Signature _________________________________ Date ____________________________________

IV PATIENT RESPONSIBILITY AGREEMENT FOR NON-COVERED SERVICES

Patient’s Name: ______________________________________ Date: _______________________________________ The purpose of this wavier form is to inform patients, before they receive a medical service, that the services listed below are deemed “non-covered” services with your insurance company. The IV Infusion procedure IS a covered benefit and will be billed to your insurance company (procedure codes 96360-96374), however the ingredients used in the products listed below are administered into the IV, and are made up of compounded minerals, and therefore have no coverage determination when billing to your insurance. Your physician believes that the following service(s), although not covered by your health insurance, are an important part of your care and recommends that you receive these services as part of your current treatment plan. However, since the services listed here are not considered to be a covered benefit under your health insurance, should you choose to receive these services; you will be personally responsible for the payment of such services. The purpose of this notice is to help you make an informed choice about whether you want to receive these items or services.

The services recommended by your physician are listed below:

Compounded DMPS 125mg $150 Compounded DMPS 250mg $200 Compounded Glutathione 1500mg $150 Compounded Glutathione 3000mg $200 Compounded Ca EDTA 1500mg $150 Compounded Ca EDTA 3000mg $200 Compounded Meyers Cocktail $100 Compounded Vitality Drip $150 Compounded Vitamin C 15g 100g $125 -$250

I acknowledge that I have been informed in advance of receiving these services, that these services are not covered by my health insurance plan. I have chosen to receive these services and understand that I will be financially responsible for the charges indicated above. Print Patient Name ________________________________________________________________________________

Patient Signature _________________________________________________________________________________

Name of Parent or Legal Guardian (if applicable) ________________________________________________________

Signature of Parent or Legal Guardian (if applicable) _____________________________________________________

Date ________________________