SMA Consent Form Coaching Clients

Shared Appointments Consent Form

Kunj Patel Medical Doctor PC DBA CRISSP Longevity Clinic
Are you the participant?

YesNo
If you are signing for the participant, please answer the following:*

I am permitted to sign for the patient as I am their legal guardian/medical power of attorney/decision maker.
My name is First Name* Last Name*, and my relationship to the participant is * .
Participant's Name*

First NameLast Name
Participant's Date of Birth (MM-DD-YYYY):

MonthDayYear
Date
Shared Appointments (SMA) are Group visits! Each person's participation is strictly voluntary.

During a typical SMA, 5 to 15 participants or coaching clients are seen together in a setting that encourages asking questions, and sharing concerns and experiences. You can learn from other participants in this environment as well as your health coaching team.

Most have been overwhelmingly satisfied with the program. They enjoy the opportunity to relate to other people who are dealing with similar issues, share stories and ideas, learn from one another and truly create a bond. Shared appointments are particularly valuable to people dealing with a variety of wellness conditions concerning their weight, energy, aging, and overall wellbeing. Everyone has the opportunity to be a role model to someone else!

If participants have individual questions that were not addressed during the shared appointment due to confidentiality or time constraints, they are encouraged to schedule a follow-up appointment to discuss those concerns in detail.
Confidentiality agreement:

Because group visits involve participants disclosing private medical and social information, all participants in a group visit – including the participant and any accompanying family members/friend – must agree to respect the privacy of ALL participants and keep their information confidential.
By signing this confidentiality agreement, I assume the responsibility for keeping all information confidential.*

Clear
Date*

MonthDayYear
Date
Waiver:

Payment for shared appointments is handled in the same manner as payment for regular/traditional medical appointments. By participating in a group visit, participants assume responsibility for the cost of the appointment or, if applicable, any Deductible, Co-pay, Co-insurance involved, including no-show fee. Note: A Reminder phone call may be made 2 business days in advance. If you wish to change/cancel, same 24-hour notice is appreciated.
By signing this form, I assume the responsibility of paying for my group-visit appointment and agree to pay any co-pays and all costs associated with this appointment.*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Shared Appointments Consent Form

Confidentiality agreement:

Waiver: