Covid Patient Form

Please initial the following:

AUTHORIZATION TO RELEASE MEDICAL INFORMATION
Signature*   I authorize the release of any medical information to specialty providers and offices necessary to further my treatment through referrals. This assignment will remain in affect until revoked by me in writing. A photocopy of this assignment is to be considered valid as an original. I understand that holistic treatments are not a substitute for medical diagnosis and treatment, and no medical claims are made regarding these treatments.

FINANCIAL AGREEMENT
Signature*  Deposit of $75 must be made at the time of scheduling. Reimbursement for scheduled office visits is available if canceled prior to 72 hours (3 business days) of appointment time. If cancellations or rescheduling occur after 72 hours (3 business days) the patient will forfeit their deposit. Balance due at time of appointment. Medication refills and focused email correspondence will incur a $50 charge for services rendered. Email correspondence is subject to no more than 2 exchanges per focused topic and request. More in depth requests may require an appointment with a provider.

CONSENT TO CARE
Signature*   I request and give consent to Dr. Veerula, the nurse practitioners, their associates and assistants who may provide medical care to perform such medical-surgical care, tests, procedures, and other necessary services as well as provide drugs and supplies as they consider necessary or beneficial for my health and well-being. I acknowledge that no representations, warranties or guarantees as to the results or cures have been made to me or relied upon by me. In addition, I understand there may be adverse effects or complications from some treatments/procedures/drugs, etc.

NO SHOW/CANCELLATION POLICY:
When you make an appointment, we are reserving time in our clinician's schedule that is no longer available to other patients. If you are unable to keep an appointment, FWIM requires that you cancel (or re-schedule) your appointment at least 72 hours (3 business days) prior to your scheduled appointment time. Deposits can be transferred to timely rescheduled appointments up to 2 times. If you cancel or reschedule within 72 hours (3 business days) or are considered a no-show, your deposit is forfeited as a no-show/cancellation fee. Breach of this policy on 3 or more consecutive occasions can be grounds for discharge from the clinic. Note that the cancellation fee may be waived in special circumstances, determined on an individual basis (eg: medical emergency, patients may be asked to provide documentation for the same).

PRE-APPOINTMENT CHECK IN POLICY:
If your appointment is scheduled for telemedicine, our staff will attempt to call you 2 times and email 30-60 minutes prior to your scheduled appointment. This call is necessary to review medications, the purpose of the appointment, review of symptoms, and confirm that your video link works. If we cannot contact you and do not hear back prior to your scheduled appointment time, your appointment will be cancelled and you will be considered a no show.