TWCC - New Patient

New Patient Enrollment
Dr. Kasper
Today's Date

MonthDayYear
Date
Patient's Full Name:*

First NameLast Name
Patient's Date of Birth:

MonthDayYear
Last 5 of SSN:*
Patient's Contact Number:*
Patient's E-mail:*
example@example.com
Patient's Mailing Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Marital Status:
Sex:
Age:
Height:
In feet, inches
Weight:*
How did you hear about us?
In case of emergency
Emergency Contact:

First NameLast Name
Relationship:
Contact Number:

Telemedicine or In Person Visit Consent
Telemedicine services involve the use of secure interactive videoconferencing
equipment and devices that enable health care providers to deliver health care
services to patients when located at different sites.
1. I understand that the same standard of care applies to a telemedicine visit as applies to an in-person visit.
2. I understand that I will not be physically in the same room as my health care provider. I will be notified of and my consent obtained for anyone other than my healthcare provider present in the room
3. I understand that there are potential risks to using technology, including service interruptions, interception, and technical difficulties.
  1. If it is determined that the videoconferencing equipment and/or connection is not adequate, I understand that my health care provider or I may discontinue the telemedicine visit and make other arrangements to continue the visit.
4. I understand that I have the right to refuse to participate or decide to stop participating in a telemedicine visit, and that my refusal will be documented in my medical record. I also understand that my refusal will not affect my right to future care or treatment.
  1. I may revoke my right at any time by contacting Woodlands Cannabis Clinic at(346) 327-4344.
5. I understand that the laws that protect privacy and the confidentiality of health care information apply to telemedicine services. Click HERE to download our Privacy Practices
6. I understand that my health care information may be shared with other individuals for scheduling and billing purposes.
7. I understand fees will be applied for and agree:
  1. I understand that there is a $75.00 fee if I am a no show/no call on the date and time of my appointment and will be charged with the card on file.
  2. I understand that there is a $50.00 fee if I reschedule my appointment within 24 hours of my appointment and will be charge with the card on file.
  3. I understand fees are due at the time of service.
8. I understand that this document will become a part of my medical record.
  By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the state of Texas and will be in Texas during my telemedicine visit(s).
Patient Signature:*

Clear
Today's Date:*

MonthDayYear
Date
Notice of Privacy Practices Acknowledgement
You have been given the Notice of Privacy Practices for Woodlands Cannabis Clinic. This notice describes your legal right regarding your health information and will inform you of the legal duties and privacy policies.

This Notice of Privacy Practices is one document for your convenience. This practice is independently responsible for complying with this Notice.

If you have a question regarding any of the information set forth in this Notice of Privacy Practices, please do not hesitate to contact Woodlands Cannabis Clinic office at (346) 327-4344.
Patient Signature:*

Clear
Today's Date:*

MonthDayYear
Date

PATIENT CONSENT FOR MEDICAL RECORDS
Do you want to share your medical records with Dr. Kasper?*

YesNo
Do you agree with Woodlands Cannabis Clinic to share your medical records with your PCP or Specialist?*

YesNo
Who is your Specialist or PCP?
- I authorize the release of health informaion as described above.
- This authorization is valid for 180 days unless otherwise stated.
- A photo copy or fax of this authorization is valid as the original.
- I may revoke this authorization at any time by submitting a revocation in writing to WCC (Woodlands Cannabis Clinic) main office.
- If I revoke this authorization, the revocation will not apply to information already released in good faith before the revocation was received.
- Treatment may not be conditioned on my completion of this authorization form.
- If the recipient identified above is not covered by Federal or Texas privacy laws, the information may not be protected under these laws once it is disclosed to the recipient and, may be subjected to re-disclosure by the recipient.
- I may be asked to provide proof of my identity/guardianship with this authorization.
- Fees/charges will comply with all laws and regulations applicable to release protected health information. Payment is due at time of release of information.
My signature indicates that I have read and acknowledge the above Consent to Treatment, Release of Information, and Notice of Privacy Practices and agree to all the terms as indicated.
Patient Legal Full Name:*

First NameLast Name
Patient Signature:*

Clear
Today's Date:

MonthDayYear
Date

Upload Valid Texas Identification or Valid Passport (MUST COMPLETE TO SUBMIT FORM):*

Cancelof
NOTICE CONCERNING COMPLAINTS

Complaints about physicians, as well as other licensees and registrants of the Texas Medical Board, including physician assistants, acupuncturists, and surgical assistants may be reported for investigation at the following address:

Texas Medical Board Attention: Investigations

333 Guadalupe, Tower 3, Suite 610

P.O. Box 2018, MC-263 Austin, Texas 78768-2018

Assistance in filing a complaint is available by calling the following telephone number:

1-800-201-9353

For more information, please visit our website at

www.tmb.state.tx.us.
Should be Empty:

New Patient Enrollment

Dr. Kasper

Medical History

Qualifying Condition

Telemedicine or In Person Visit Consent

Notice of Privacy Practices Acknowledgement

PATIENT CONSENT FOR MEDICAL RECORDS