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You are allowed to cancel or reschedule your appointment--free of charge-- up to 24 hours prior to your scheduled time slot.
cancellations within 24 hours prior to the appointment and no shows are non-refundable.


I consent to allow Dexafit Rhode Island and/or DexaFit, Inc. to use their DXA scanner to perform a body composition and/or bone densitometry scan, with full awareness that the technology uses low-dose x-rays. 

I also authorize Dexafit Rhode Island and/or DexaFit, Inc. to use or review my de-identified records for research purposes and/or to determine my qualifications for approved clinical studies and to contact me if I have potential as a research candidate. 

I accept financial responsibility for all charges for services provided to me and/or my family members. 

1. I do hereby release all representatives of Dexafit Rhode Island and/or DexaFit, Inc. 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 Dexafit Rhode Island and/or  DexaFit, Inc.
2. I am voluntarily participating in the Dexafit Rhode Island and/or DexaFit, Inc DXA scan service and/or other including 3D scan, RMR and VO2max 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 Dexafit Rhode Island and/or DexaFit, Inc. 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.  I also certify that I am not pregnant or trying to become pregnant.   
4. I take full responsibility for any action taken by me after my visit to Dexafit Rhode Islandand/or DexaFit, Inc. I do not hold any representatives of Dexafit Rhode Island or DexaFit, Inc responsible or liable for any adverse effects or complications arising from the services or opinions offered by them. 

5. Confidentiality. The information based on the observations made during the DXA scan, VO2max, or RMR analysis, and subsequent report is treated as privileged and confidential. However, it may be used for statistical or scientific purposes with your right to privacy retained. 

6. I understand that Dexafit Rhode Island and/or DexaFit, Inc 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. 

‘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 Dexafit Rhode Island and/or DexaFit, Inc 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 Rhode Island 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. 

I hereby authorize Dexafit Rhode Island and/or DexaFit, Inc 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 DexaFit website. I also understand that this Authorization 
is subject to revocation/withdrawal by me at any time in writing to Dexafit Rhode Island , except to the extent that the action has already been taken to release this information. This Authorization shall remain valid unless revoked. Dexafit Rhode Island and/or DexaFit, Inc will not forward my health and fitness information if I do not consent to this Authorization. 

Consent Form for VO2:
1. Purpose and Explanation for the Test 
You will perform a graded exercise test on a motor-driven treadmill or stationary bike. The exercise intensity will begin at a low level and will be advanced in stages, depending on your fitness level. We may stop the test at any time because of signs of fatigue or changes in your heart rate or blood pressure, or symptoms you may experience. You may stop the test at any time because of feelings of fatigue or any type of discomfort. 
2. Attendant Risks and Discomforts 
As with any exercise, there exists the possibility of certain changes occurring during the test. These include abnormal blood pressure, fainting, irregular, fast or slow heart rhythm, and in rare instances, heart attack, stroke, or death. Every effort will be made to minimize these risks by evaluation of preliminary information related to your health and fitness and by careful observation during testing. Please note that there will NOT be a physician present on site. 
3. Responsibilities of the Participant Information you possess about your health status or previous experience of exercise-related or heart-related symptoms (such as shortness of breath with low-level physical activity, pain, pressure, tightness, or heaviness in the chest, neck, jaw, back, and/or arms) may affect the safety of your test. Your prompt reporting of these and any other unusual feelings with effort during the test is of great importance. You are responsible for disclosing your medical history, as well as symptoms that may occur during the test. You are also expected to report to the facility ANY condition that might make the test unsafe for you. 
4. Benefits to be Expected 
5. Inquiries Any questions about the procedures used in the exercise test or the results of your test are encouraged. If you have any concerns or questions, please feel free to ask via email at prior to the test
I hereby consent to engage in an exercise test to determine my exercise capacity. My permission to perform this test is given voluntarily. I understand that I may stop the test at any point, if I so desire. I have read this form and I understand the test procedures that I will perform and the attendant risks and discomforts. I understand that there will NOT be a supervising physician onsite. Knowing these risks and discomforts, and having an opportunity to ask questions that have been answered to my satisfaction, I consent to participate in the test.


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