Thank you for choosing Garcia Heart and Vascular Clinic.

Before we offer you complimentary water or coffee, we'd love to hear about your experience, and ask you to sign a quick consent form.

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Thank you! Your feedback helps us serve you and your family better. Now, please take a moment to read and sign our beverage consent form.

This consent form is available in English, Spanish, and Portuguese. All versions are equally valid.

COMPLIMENTARY BEVERAGE CONSENT & LIABILITY ACKNOWLEDGMENT

GARCIA HEART & VASCULAR PLLC

Date:

Complimentary Refreshments

At Garcia Heart & Vascular, we are pleased to offer our patients complimentary bottled water and freshly brewed coffee as a courtesy during their visit.

Before accepting these complimentary beverages, please read the following. By selecting “I Agree”, I acknowledge and agree that:

Language Access: Title VI Notice

This consent form is available in English, Spanish, and Portuguese. All versions are equally valid. If you need assistance in another language, please notify a staff member before signing.

I understand that bottled water and coffee are provided solely as complimentary refreshments and are not part of my medical treatment or care. I understand that coffee contains caffeine and that consuming caffeine may not be appropriate for individuals with certain medical conditions, including but not limited to high blood pressure, heart disease, cardiac arrhythmias, pregnancy, anxiety disorders, gastrointestinal conditions, allergies, or caffeine sensitivity. I understand that I am solely responsible for deciding whether these beverages are appropriate for me based on my own medical history, allergies, dietary restrictions, or advice from my healthcare provider. I voluntarily choose to consume these complimentary beverages at my own discretion and assume any risks associated with their consumption. To the fullest extent permitted by applicable law, I release and hold harmless Garcia Heart & Vascular PLLC, its physicians, employees, contractors, officers, and agents from any claims, damages, injuries, losses, or liabilities arising from my voluntary consumption of these complimentary beverages, except where prohibited by law, including claims resulting from gross negligence or willful misconduct. I understand that if I have any concerns regarding caffeine, allergies, food sensitivities, dietary restrictions, or any medical condition that could be affected by these beverages, I should decline them or speak with a member of the clinic staff before consuming them.

You're all set!

Your consent has been recorded. Please enjoy your complimentary water or coffee. Our team is here if you need anything.

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No problem.

You have not agreed to the terms, so we won't be able to offer complimentary water or coffee today. If you have any questions, please speak with a member of our staff.