This form is to enroll in our Health Initiatives pipeline and speak to a member of our team about Health/Wellness concerns and discuss options for sponsored treatment through our DAGGER pipeline.  If you need emergency financial assistance instead, please fill out the Immediate Needs Enrollment Form located here - 

https://form.jotform.com/TFdagger/tfd-HI-enrollment-form

I hereby consent to be referred by TFD for a medical evaluation, if recommended as a result of my discovery call with TFD Services Team. I understand that the purpose of this referral is to obtain medical advice and treatment from a licensed healthcare provider.

I acknowledge that TFD is not a healthcare provider and is solely facilitating the referral. I further understand that I will be clearly informed if TFD will offer to cover the costs associated with the medical evaluation.

I authorize TFD to share my contact information and relevant medical history with the healthcare provider for the purpose of the evaluation. 

I understand that the healthcare provider to whom I am referred is responsible for all medical advice and treatment. I acknowledge my right to seek a second opinion or explore alternative treatment options.

I acknowledge that any offer on TFD’s part to cover the cost of the medical evaluation is a charitable act, and that TFD is not assuming any liability for the evaluation or subsequent treatment.

By signing below, I confirm that I have read and understood the information provided in this consent form, and I voluntarily consent to the referral for a medical evaluation, with costs potentially covered by TFD.