Online Patient Appointment & Consent Form

Online Patient Appointment & Consent Form
Online Patient Appointment & Consent Form
Welcome! Please note, that this clinical service is ONLY for those who do not have insurance and are not financially able to afford basic health services.

If you have any type of insurance (Medicaid, Medicare, ObamaCare etc) or are financially able to afford health insurance, then kindly DO NOT request an appointment.

Our electronic medical record system checks if you have insurance. If we discover that you have insurance, then you will not be given an appointment and any existing appointments will be cancelled.

IMPORTANT NOTICE: We DO NOT provide emergency medical services or urgent care visits. In case of an emergency, call 911 or go to your nearest emergency room.

DISCLAIMER: We DO NOT prescribe or dispense controlled substances. This includes, but is not limited to, medications such as opioids (e.g., oxycodone, hydrocodone), benzodiazepines (e.g., alprazolam, diazepam), and stimulant medications (e.g., amphetamines, methylphenidate).
You are legally agreeing to the above statement and confirming by clicking "YES"*
Do you have Insurance?*
Reason for Appointment*
Please briefly describe your complaint. For example, need medication refills, well check, ear pain etc.
Appointment Type*
Clinic Location*
Patient’s Full Name*

First NameLast Name
Gender:*
Date of Birth:*

MonthDayYear
DOB
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Number*

Area CodePhone Number
Email*
example@example.com
Marital Status?*
Emergency Contact Person
Full Name*

First NameLast Name
Relationship*
Phone Number*

Area CodePhone Number
Notice of Privacy Practices, Release of Billing Information, Consent for Treatment and Assignment of Benefits.
Form in Spanish
Date*

MonthDayYear
Date
Are you signing in for a minor?*
If patient is minor, please specify the relationship to the patient*
Your Name:
First Name, Middle Initial, Last Name
Take a picture of a valid form of ID (driver license, passport, greencard, etc).*

Cancelof
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Online Patient Appointment & Consent Form

Online Patient Appointment & Consent Form

Emergency Contact Person