I give permission to Brij Health to perform the following services that the physicians and other non‐physician providers and assistants may deem to be necessary:
(a) medical, surgical, and diagnostic (e.g.: including, but not limited to, x‐rays, blood draws, and laboratory tests) processes, treatments, and procedures;
(b) administration of injections, medications, and immunizations (with immunizations to occur after my receipt of any applicable vaccine information statements (“VIS” or “VISs”); and
(c) completion of medically appropriate tests for communicable and other diseases.
I give permission to Brij to perform a wellness and/or preventative health screening. I understand that I am solely responsible for following up with my personal physician or other healthcare provider about the results of my screening. In performing the wellness screening, Brij does not assume any responsibility for ongoing treatment or management of care.
Your name and signature below indicate that you have been made aware of Brij’s Notice of Privacy Practices (NOPP) on the date indicated. You understand that the NOPP is posted in the center and a copy will be provided to you if you request it. If this is your first date of service with Brij, please indicate this to the front desk receptionist and he/she will provide you a copy of the NOPP. If you have any questions regarding the information in Brij’s Notice of Privacy Practices, contact Brij’s Privacy office at 952-479-0814 or nurseline@care.dev.brijhealth.com