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.
Vela Wellness (“Vela” or “we”) is a physician-led medical wellness clinic providing personalized healthcare services.
Our services include:
All services are provided by licensed healthcare providers in Iowa.
Availability may vary based on medical history and clinical appropriateness.
Results are not guaranteed.
We make no warranties regarding outcomes or long-term effectiveness.
Vela’s services are supplementary and not a replacement for primary or specialty care.
You agree to:
You agree to seek emergency or follow-up care when needed.
You consent to agreed-upon treatment and services.
Your provider will explain:
You may refuse treatment at any time.
Completing assessments does not guarantee prescriptions.
All decisions are made by licensed providers.
You agree to:
You may obtain medications from:
Medication costs are separate.
Compounded medications:
Examples include Ozempic®, Wegovy®, Mounjaro®, and Zepbound®.
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 is due at time of service.
Accepted methods:
Memberships require monthly fees.
You authorize automatic billing.
Failed payments incur a $25.00 late fee.
You agree to:
Failure may result in termination of services.
24-hour notice required.
Fees:
Medications: Non-refundable
Services: Non-refundable
Prepaid Packages: Refund minus 20% fee
Memberships: Non-refundable
Unused benefits are forfeited.
SMS / TEXT MESSAGING TERMS
By opting in to receive SMS messages from Vela Wellness Clinic, you agree to the
following terms:
Program Description: Vela Wellness Clinic uses SMS messaging for appointment reminders,
health and wellness tips, promotional offers, and service-related communications.
Message Frequency: Message frequency varies depending on your interactions with us
and the services you have enrolled in.
Opt-Out: You may opt out of SMS messages at any time by replying STOP to any message.
After opting out, you will receive one final confirmation message and will no longer
receive SMS messages unless you re-opt in.
Help: For assistance, reply HELP to any message or contact us at (319) 201-0004 or
info@velawellnessclinic.com.
Message & Data Rates: Standard message and data rates may apply. Check with your
wireless carrier for details.
Carrier Disclaimer: Vela Wellness Clinic and mobile carriers (including T-Mobile,
AT&T, Verizon, and others) are not liable for delayed or undelivered messages.
Age Restriction: You must be 18 years of age or older to opt in to receive SMS
messages from Vela Wellness Clinic.
Privacy: Your mobile phone number and information collected through SMS opt-in will
not be sold, shared, or rented to third parties for marketing purposes. See our
Privacy Policy at velawellnessclinic.com/privacy-policy for full details.
Including:
Messages may be automated.
Rates may apply.
You may opt out anytime.
For help, reply HELP or contact:
info@velawellnessclinic.com
You must create an account to access certain services.
You agree to:
You are responsible for account activity.
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.
By signing, you confirm that:
Patient Signature: _____________________________
Date: _____________________________
#90384520 (rev. Jan. 2026)
