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Online Medical Consent Form
Patient Information
Name
*
Age
*
Date of Birth
*
-
Month
-
Day
Year
Sex
*
Please Select
Male
Female
Email
*
example@example.com
Phone Number
*
Health Insurance Name
Insurance Policy ID
Insurance Package/Type
Parent/Guardian or Emergency Contact Details
Contact Person Name
Primary Phone Number
Medical Data
Blood Type
Please Select
A
B
AB
O
Are you wearing glasses or contact lenses?
Yes
No
Do you have any known allergies? If yes, then please specify below.
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma, cancer, etc.?
Acknowledgment, Authorization and Waiver
Type a question
I authorize Morphoneogenesis LLC to perform the clinical treatment to me.
I confirm that the Clinical Physiologist explained the procedure thoroughly to me and how it will help me with my current condition.
I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
I acknowledge that all information I provided in this form is true and accurate.
Patient/Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Submit
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