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 SMS messaging/audio and/or audio video telehealth consultations. 

I understand the Valjalah provider fee $20 is separate from the prescribed medication costs and is a legally required payment for a board certified medical provider to review your health info, diagnose your condition, and write you ONE prescription for your personalized treatment for 6 months, or $50 for all three. 

I also understand that the one on one zoom consultation fee is separate from the medication costs