Patient Name: _______________________________
Date of Birth: ______________________________

Address: ____________________________________

Phone Number: ___________________________
Email Address: ____________________________

Please read this form carefully before signing.

Do NOT sign this form until all your questions have been answered.

By signing below, you agree to abide by these terms.

Our Services

Vela Wellness (“Vela” or “we”) is a physician-led medical wellness clinic providing personalized healthcare services.

Our services include:

• Medical weight loss programs (GLP-1: semaglutide, tirzepatide)
• Hormone replacement therapy (HRT)
• Peptide therapies
• Health coaching
• Aesthetic treatments
• IV therapy and vitamin injections
• Laboratory testing
• Telehealth consultations
• Membership and subscription programs

All services are provided by licensed healthcare providers in Iowa.

Availability may vary based on medical history and clinical appropriateness.

No Guarantee

Results are not guaranteed.

We make no warranties regarding outcomes or long-term effectiveness.

Your Duty to Maintain Relationship with Your Primary Care Provider

Vela’s services are supplementary and not a replacement for primary or specialty care.

You agree to:

• Maintain a relationship with a qualified provider
• Consult them regarding your conditions
• Inform Vela of any concerns

You agree to seek emergency or follow-up care when needed.

Your General Consent to Treatment

You consent to agreed-upon treatment and services.

Your provider will explain:

• Purpose
• Benefits
• Risks
• Side effects
• Alternatives

You may refuse treatment at any time.

Prescription Medications

No Guarantee of Specific Prescriptions

Completing assessments does not guarantee prescriptions.

All decisions are made by licensed providers.

You agree to:

• Use medications as prescribed
• Not share or resell medications

Medication Fulfillment

You may obtain medications from:

• Vela provider
• Compounding pharmacy
• Retail pharmacy

Medication costs are separate.

Compounded Medications Disclosure

Compounded medications:

• Are not FDA approved
• Are not equivalent to brand-name drugs
• May differ in quality and effectiveness

Examples include Ozempic®, Wegovy®, Mounjaro®, and Zepbound®.

Your Financial Responsibility

Cash Pay (Self-Pay) Only

Vela is a self-pay practice.

You are responsible for all charges.

We do not bill insurance.

Invoices may be used for reimbursement requests.

Coverage is not guaranteed.

Payment Due at Time of Service

Payment is due at time of service.

Accepted methods:

• Credit cards
• Debit cards
• HSA/FSA
• Cash
• Checks (with approval)

Recurring Payments

Memberships require monthly fees.

You authorize automatic billing.

Failed payments incur a $25.00 late fee.

Late Fees and Collections

• $25.00/month after 30 days unpaid
• Services may be suspended
• Accounts may be sent to collections
• Collection costs are your responsibility

Your Interactions with Our Providers and Staff

You agree to:

• Provide accurate information
• Treat staff respectfully

Failure may result in termination of services.

Cancellation, Late, and Refund Policies

Appointment Cancellation

24-hour notice required.

Fees:

• $50.00 for late cancellation or late arrival
• $75.00 for no-shows

Refund Policy

Medications: Non-refundable
Services: Non-refundable
Prepaid Packages: Refund minus 20% fee
Memberships: Non-refundable

Unused benefits are forfeited.

Consent to Receive Communications

You agree to receive:

• Voicemails
• Emails
• SMS messages

Including:

• Appointment reminders
• Billing notices
• Updates
• Surveys
• Health tips

Messages may be automated.

Rates may apply.

You may opt out anytime.

For help, reply HELP or contact:
info@velawellnessclinic.com

Your Account Registration

You must create an account to access certain services.

You agree to:

• Provide accurate information
• Keep it updated
• Protect credentials
• Report unauthorized use

You are responsible for account activity.

Contact Information

If you have questions, contact:

VELA WELLNESS
310 3rd Ave SE
Cedar Rapids, IA 52401
Email: info@velawellnessclinic.com
Phone: 319-201-0004
Website: www.velawellness.com

Do not sign until all questions are answered.

Acknowledgment and Signature

By signing, you confirm that:

• You read this form
• You understand it
• You agree voluntarily

Patient Signature: _____________________________
Date: _____________________________

#90384520 (rev. Jan. 2026)

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