Medical Consent Form

Name

First NameLast Name

Email

example@example.com

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Male or Female

Date of Birth

Height

Weight

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Current medical conditions

Current medications/supplements:

List any skin or drug allergies:

List previous surgeries:

List any history or family history of cancers:

Do you currently have or have you had any type of cancers? If so please list:

Do you have a history of thyroid medullary cancer?

Pregnant or Nursing:

Planning on getting pregnant soon?

How much alcohol do you drink weekly?

How much tobacco do you smoke daily?

How many days a week do you work out?

Your main goals:

Is there anything your doctor should know before writing a prescrition

Who can we thank for referring you?

I acknowledge that all my medical information given above is true and accurate. I have been informed about the risks and possible consequences of medical treatment and give permission for Amber Cotton, APRN, FNP-BC to provide me an appropriate medical treatment.

Also, I have read and accepted the clarification text on how my personal data is collected, transferred and how my data will be stored. This informed consent is to acknowledge that I got clear and comprehensive information about any medications prescribed to me including the risks and benefits. This is also to acknowlege that I consent for rovider to use or disclose health care information for treatment, payment and healthcare.

I understand that my health information is private and confidential. I understand that medical providers strive to protect my privacy and preserve the confidentiality of my personal health information.

I understand, that by signing this document my provider may use and disclose my personal health information to help provide health care to me, to handle billing and payment, and for other health care operations, failure to signt this document may result in the physician or medical provider declining treatment to me.

I consent to audio and/or audio video telehealth consultations.

Signature

Date