Consent For Medical Treatment
I voluntarily present to Well Now Physicians, PC and consent to a telemedicine consultation and treatment by the physician, nurse practitioner or physician assistant on duty and whomever they may designate as their assistant, associate, and patient care staff to provide my care. Such care may include, but is not limited to, diagnostic procedures and the administration and/or prescription of medications considered advisable in my diagnosis, treatment and care. I acknowledge that no guarantee can be made or has been made as to the results of treatment or examination and I understand that all medical treatments contain inherent risks.
I hereby consent to medical evaluation and treatment as deemed medically necessary by the Well Now Physicians, PC physician, nurse practitioner or physician assistant on duty and the WellNow center’s supporting staff.
Acknowledgement of Receipt of Notice of Privacy Practices
By signing below, you voluntarily present to Well Now Physicians, PC and consent to treatment and acknowledge receipt of the Notice of Privacy Practices of WellNow Centers. You further pledge that to the best of your knowledge, the information provided is accurate and reliable upon date of signature.
Medical Authorization and Release
I am the worker/patient listed above and I hereby authorize WellNow and WellNow Physicians PC to release to the individual or organization listed above, the following medical information from my personal medical records:
I do not give permission for any other use or re-disclosure of this information.
In consideration for such services being rendered on my behalf, I hereby RELEASE WellNow and WellNow Physicians PC from any and all claims which I might otherwise have due to such results being made available. I hereby CONSENT TO NOT FILE ANY ACTION at law or inequity and I hereby agree to INDEMNIFY and HOLD HARMLESS WellNow and WellNow Physicians PC their respective officers, agents, or employees from all damages, expenses, reasonable attorney's fee, and costs of court which they or any of them may suffer or incur, jointly or severally, due to the results of such testing or records being made available.