Informed Consent & Patient Agreements

I hereby authorize the staff employed by Anywhere Clinic/Calm Clinic to release all medical information requested by my health insurance carrier or any other third-party payers. I further authorize the release of all medical information to my referring physician and/or primary care physician. I also authorize contact with my insurance company or health plan administrator to obtain all pertinent information regarding coverage and payments under my policy. I direct the insurance company or health plan administrator to release such information to my practitioner. I authorize release of all records upon request.

I authorize the staff employed by Anywhere Clinic/Calm Clinic to access any records related to my care as needed, and to fax or electronically transmit forms or medical records upon my emailed request. I also authorize Anywhere Clinic/Calm Clinic to send telecommunication reminders via email, text message, or phone call.

I understand that text messaging (SMS) is not a fully secure method of communication and may carry some risk to the privacy of my Protected Health Information (PHI). These risks include, but are not limited to, the potential for unauthorized access, misdelivery, or interception of messages.

By agreeing to this consent, I acknowledge and agree to the following:

I authorize Anywhere Clinic/Calm Clinic to communicate with me via SMS (text messaging) regarding:

• Appointments, scheduling, and follow-ups
• Treatment updates or care coordination
• Prescription information (including refills or bridge prescriptions)
• Referrals to other providers
• Other information related to my care that may be considered PHI

I voluntarily request my physician to evaluate and treat my condition.

I understand that the prescribed medications may include anti-anxiety, insomnia, ADHD, or other psychiatric drugs, which can be harmful if taken without medical supervision. I understand these medications may lead to physical dependence and/or addiction and may produce adverse side effects or complications.

Alternative treatments, risks, and complications have been explained to me. I understand this list is not exhaustive and may include rare outcomes, including death.

I understand and consent to any required medical tests, random drug screening with less than 24 hours' notice, and psychological evaluations if necessary. Refusal to comply may result in termination of treatment.

To the best of my knowledge, I am not pregnant. If I am not pregnant, I agree to use appropriate contraception during the course of treatment. I understand the risks of taking medication(s) during pregnancy and will notify my physician immediately if I become or suspect I may be pregnant.

The goal of treatment is to manage my condition and improve my quality of life. I understand some treatments may be long-term, and tapering off medications may be part of my care plan.

I may also be referred to psychotherapy or other mental health support as part of a restorative care program. I understand that I may discontinue treatment and will be supported with appropriate supervision if needed.

• Constipation
• Nausea or vomiting
• Drowsiness or sleepiness
• Itching
• Urinary retention
• Low blood pressure
• Irregular heartbeat
• Insomnia
• Depression
• Impaired judgment or reasoning
• Respiratory depression
• Impotence
• Medication tolerance
• Physical/emotional dependence
• Addiction
• Death

By receiving care at Anywhere Clinic, I authorize my provider to use a HIPAA-compliant scribe AI tool for medical documentation and note-taking. I understand that parts of my session may be recorded solely for the purpose of creating accurate clinical records and that these recordings are securely stored according to HIPAA regulations.

This Controlled Substance Agreement outlines the responsibilities of the patient and physician and is part of the medical record.

I understand and agree to the following:

• I will receive all prescriptions for controlled medications from my designated physician only.
• All prescriptions must be filled at one (1) designated pharmacy.
• I will take medications exactly as prescribed and follow all treatment rules.
• Failure to comply may result in discontinuation of medication and/or termination of care.
• Use of illegal drugs or alcohol may result in immediate discharge from care.
• I consent to drug testing at any time, without notice.
• I will not share, sell, or give my medications to anyone.
• I will secure my medications and understand lost/stolen meds may not be replaced.
• I will inform my physician of all medications prescribed by others and any scheduled surgeries or procedures.
• I will not obtain medications from other sources (including urgent care or ER) without notifying my physician.
• I understand that the State of Nevada monitors all controlled substance prescriptions and my physician may access this data.
• I will notify my provider at least 5 business days before running out of medication to request refills.
• Early refills are not permitted, but travel arrangements can be made in advance.
• My physician may taper or stop medications if treatment is not effective or safe.

• I am not currently using illegal substances or undergoing addiction treatment.
• I have read, understood, and had the opportunity to ask questions about this agreement.
• I understand this document and consent to the treatment terms.
• My signature or e-signature constitutes a legal agreement with Calm Clinic and its terms.

I authorize direct payment of medical benefits to Dr. Sam Zand, D.O. and the staff of Anywhere Clinic/Calm Clinic for services rendered.

I understand I am financially responsible for any balance not covered by insurance unless otherwise prohibited. Co-pays and cash payments are due at the time of service unless prior arrangements are made.

I certify that all information provided in my application for benefits is accurate and authorize payment of eligible benefits on my behalf. A photocopy of this authorization is valid as the original.

Unpaid balances older than 30 days may result in cancellation of upcoming appointments if not resolved.

We understand that life can be unpredictable. If you need to cancel your appointment, please notify us at least 24 hours in advance so we can offer your time slot to another patient.

No-show fees apply for late cancellations:

By scheduling an appointment, you acknowledge and accept this policy. We appreciate your cooperation in helping us provide timely care to all patients.

• $60 for new patient appointments
• $30 for follow-up visits

The following applies only if you participate in the Ketamine Therapy Program (KTP):

• I understand my participation in the KTP may be terminated at any time by Anywhere Clinic.
• I will attend at least one monthly appointment with my provider (or more if recommended).
• Repeated cancellations or no-shows may result in discharge from the program.
• Each ketamine session lasts approximately two hours.
• My blood pressure must be consistently below 140/90 to begin treatment.
• I will notify my provider of any history of heart attack, stroke, aneurysm, or uncontrolled hypertension.
• I will not drive or operate any vehicles for at least 6 hours after treatment.
• I will avoid intense physical activity for 6 hours post-treatment.
• I will have a Peer Support person (friend/family) present for all at-home ketamine sessions.
• I will pay all invoices from Anywhere Clinic when due.