CONSENT FORM

Please read each statement carefully and INITIAL to acknowledge your understanding and agreement.

Initials: initial I understand that I have not formally established medical care with Dr. Shaida Sina or Breakthrough Medicine. The laboratory order provided is a professional service intended to obtain health data prior to my initial consultation. Ordering these labs does not establish a physician–patient relationship until I complete an initial consultation and am formally accepted as a patient.
Initials:   initialI understand that the purpose of these laboratory tests is to help prepare for my initial consultation, during which results will be reviewed and treatment recommendations may be discussed.
Initials:   initialI understand that Breakthrough Medicine is not responsible for monitoring my health status prior to my consultation appointment. If I experience worsening symptoms, new symptoms, or a medical emergency, I agree to seek care from my current physician, urgent care, or the nearest emergency department.
Initials:   initialI understand that laboratory testing may identify abnormal results, and that interpretation of results will occur only during my scheduled consultation unless a separate medical appointment is arranged.
Initials:   initialI acknowledge that this laboratory order is provided as a convenience service to expedite my care, and that I may be responsible for any costs associated with laboratory testing depending on the laboratory used and my insurance coverage.
Initials:   initialI understand that laboratory results will not be interpreted by email, phone, or messaging prior to my consultation unless a formal appointment is scheduled.
Initials:   initialI acknowledge that it is my responsibility to complete ordered laboratory testing in advance of my consultation appointment whenever possible.
Initials:   initialI understand that Breakthrough Medicine communicates with patients electronically (email, electronic forms, or patient portal) and that these communications may contain protected health information. By signing this form I consent to electronic communication related to scheduling, laboratory testing, and care coordination.
Initials:   initialI understand that missed or canceled consultations with less than 24 hours notice may result in a cancellation fee according to clinic policy.