·      I acknowledge that undergoing a REMS evaluation performed by our physician or staff does not establish a physician- patient relationship. 

·      I acknowledge a brief review of results will be performed at the time of the REMS evaluation which includes an opportunity to view the report on the screen at the time the report becomes visible on the monitor.

·      I acknowledge that an in-depth review of my results will not be performed at the time of the REMS evaluation. Education/consultation regarding my REMS report is available at a separate appointment via video or phone conference.

·      I acknowledge that if the REMS report is performed at my physician’s office, my treating physician will receive a copy of my REMS report. My physician will review the report with me at a scheduled appointment.  I will not receive a report at the time of the REMS evaluation.

·      I acknowledge that if I undergo a REMS evaluation at an event conducted outside of my physician's office, I will receive a USB thumb drive with my report. It is my responsibility to share my report with my physician. Qualis Os will not share your information with a third party.

·      I acknowledge that Qualis Os by Z Medical Solution, LLC does not accept insurance of any kind. Direct payment for service is accepted.

·      I acknowledge that a non-refundable fee will be charged by Z Medical Solution LLC to schedule a REMS evaluation. There will be no refunds for rescheduling or cancellations. 

·      I will not hold responsible ZMS staff and representatives for any injury that may occur related to maintenance of the premises of any location where the service is being provided. Clients entering the location of the service assume full responsibility for their actions and consequences - accident, injury, or loss of personal property.