Appointment Request

Your Name*

FirstLast
Is this release form regarding yourself?*

YESNO
Patient's Name*

FirstLast
Your Relationship to the Patient*
If Other, Please Specify*
Phone*
Email*
Address*

Address Line 1

Address Line 2

CityState

Zip Code
Are you representing a business?*

YESNO
Business Name*
Address*

Address Line 1

Address Line 2

CityState

Zip Code

Additional Comments
File Upload

Please only submit images you have the rights to. If you have additional images you would like to share, please feel free to send them to info@jrmcnd.com.
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Authorization*

I authorize my signature.
I authorize Jamestown Regional Medical Center and those acting on behalf of Jamestown Regional mEdical Center to photograph, film, or record me and use these images or recordings in JRMC's marketing. This includes, but is not limited to, print and broadcast media, JRMC's website and newsletters or other social media such as Facebook, Instagram, Twitter, LinkedIn, Pinterest and YouTube. I realize I will not be paid for this service and hereby release Jamestown Regional Medical center, its staff and physicians, from any liability which may result from this content.
Stay in Touch With JRMC*

I'd like to receive information by mail, like JRMC AppleSeeds.I'd like to receive JRMC Foundation's email updates.Please remove me from all future Foundation communication.
The privacy provisions of the Federal Health Insurance Portability and Accountability Act of 1996 (HIPAA) apply to health information created or maintained by healthcare providers who engage in certain electronic transactions, health plans and healthcare clearinghouses. HIPAA governs how healthcare providers like JRMC handle patient information. HIPAA permits JRMC and its institutionally related foundation, JRMC Foundation, to use certain information (e.g. patient ID, name, address, telephone number, dates of service, age and gender) to contact you in the future to raise funds for the benefit of JRMC, provided that patients are given the opportunity to "opt-out" of such fundraising communications.

Patient privacy opt-out is only for past and current patients of JRMC. We will honor your request not to receive fundraising communications from the JRMC Foundation after the date we receive your request.
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