PMW Patient Registration

Patient's Full Name

First NameLast Name

Date of Birth

Date

Address.

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Phone Number

Format: (000) 000-0000.

E-mail Address

example@example.com

Appointment Address (If different from home address)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contact

First NameLast Name

Phone Number

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

Gov’t Issued ID

Insurance Card (If applicable for lab processing)

Height

Weight

Please give information about patients health.

Rows	Yes	No	Unknown
Are you presently under medical care?
Do you have any drug allergies?
Have you ever tested positive for a blood borne pathogen? (ie, tuberculosis, HIV, Hep B/C)
Have you ever fainted or are prone to fainting during/after a blood draw or injection?

Ordering/Referring Provider (If applicable).

First NameLast Name

Phone Number

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

Lab Order/Requisition (REQUIRED if ordered by Physician)

Fasting required?

The health information that you provide is under the protection of the federal Health Insurance Portability and Accountability Act (HIPAA). We can use your health information for purposes of treatment, payment and health care operations. Under HIPAA, you have the right to Request restrictions on how we use or disclose your health information in certain circumstances, including for treatment, payment or health care operations. We do not have to agree to your request unless you request restriction on disclosures to a health plan for purposes of payment or healthcare operations, and the health information relates to an item or service for which you, or another person on your behalf, have assumed full financial responsibility. If we do agree to your restrictions, we will be bound by our agreement except in limited circumstances, such as if there is an emergency.

GENERAL SERVICES: By scheduling this appointment with Precision Med & Wellness LLC (PMW), I voluntarily consent to the service(s) selected for my appointment, including mobile specimen collection (lab work), vital signs, injection education or administration. I understand that I may ask questions and may decline or stop a service at any time.

INJECTION EDUCATION: For injection education and/or administration, I understand that PMW will provide the service as authorized or ordered, when applicable. I understand that injection education does not replace medical advice from my prescribing provider. I authorize PMW to provide injection education and/or administer the injection(s) selected for my appointment. I agree to provide accurate information regarding my medication and any relevant allergies or reactions and to notify PMW of any concerns or adverse reaction. PMW reserves the right to decline administering any injectables that are not clearly labeled, have been pre-drawn prior to their arrival, or if the vial appears to have been tampered with.

MOBILE SERVICE & PATIENT RESPONSIBILITY: I understand that PMW provides mobile services that are subject to the applicable service description, availability, and any provider orders or requirements. I agree to provide accurate and complete information and to notify PMW of any relevant changes.
When applicable, I authorize PMW to communicate provider-ordered test results to my provider only. I understand that PMW will not disclose these provider-ordered test results to other persons or entities under this authorization unless otherwise permitted or required by law.

PAYMENT, CANCELLATION & TRAVEL: Payment is due at the time of service. Mobile service includes travel within 0-20 miles. A $25 travel fee applies to 21-35 miles, and a $40 travel fee applies to locations over 35 miles, subject to PMW discretion.

PRIVACY & COMMUNICATION: Precision Med & Wellness LLC (“PMW,” “we,” “us,” or “our”) respects your privacy and is committed to protecting your personal information. PMW may collect information you provide when you contact us, schedule an appointment, complete forms, or receive services. This may include your name, contact information, appointment information, payment information, and health information needed to provide services.

We use your information to schedule and provide services, communicate with you, process payments, coordinate laboratory services, maintain business records, and comply with applicable laws.

When applicable, PMW protects and handles protected health information (PHI) in accordance with the Health Insurance Portability and Accountability Act (HIPAA) and other applicable privacy requirements. We only use or disclose health information as permitted or required by law or as authorized by you.

PMW uses reasonable safeguards to protect your personal and health information. We do not sell your personal information.

PMW may use trusted third-party services for scheduling, payment processing, communications, website hosting, and laboratory services. Information may be shared with these services only as necessary to provide services or as required by law.

PMW may update this Privacy Policy as needed. Any updates will be posted on this website.

For questions about this Privacy Policy or your information, please contact Precision Med & Wellness LLC through the contact information provided on this website.

ACKNOWLEDGMENT: I understand that PMW services do not replace evaluation, diagnosis, treatment, or emergency care by my healthcare provider. When appropriate, PMW may recommend that I contact my healthcare provider or seek emergency medical care.

Agreement

Patient Registration

HEALTH INFO

Services

PRIVACY NOTICE

Consent To Services