Our clinic can offer you a blood pressure cuff or weight scale that automatically sends the numbers to our clinic, and this would be covered by your insurance (the clinic will verify first). If you are interested, choose one:
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Cellular Blood Pressure Monitor
Cellular Weight Scale
Not interested
Remote Patient Monitoring/Remote Therapeutic Monitoring Consent
Signature
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Are you the patient?
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Yes
No
If you are signing for the patient, please answer the following:
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I am permitted to sign for the patient as I am their legal guardian/medical power of attorney/decision maker.
My name is
First Name
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Last Name
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,
and my relationship to the patient is
blank
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.
Patient's Name:
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First Name
Last Name
Patient's Date of Birth (MM-DD-YYYY):
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Submit
Should be Empty: