This form is to enroll in our Health Initiatives pipeline and speak to a member of our team about Health/Wellness concerns and discuss options for sponsored treatment through our DAGGER pipeline.  If you need emergency financial assistance instead, please fill out the Immediate Needs Enrollment Form located here - 

https://form.jotform.com/TFdagger/tfd-HI-enrollment-form

I hereby consent to be referred by TFD for a medical evaluation, if recommended as a result of my discovery call with TFD Services Team. I understand that the purpose of this referral is to obtain medical advice and treatment from a licensed healthcare provider.

I acknowledge that TFD is not a healthcare provider and is solely facilitating the referral. I further understand that I will be clearly informed if TFD will offer to cover the costs associated with the medical evaluation.

I authorize TFD to share my contact information and relevant medical history with the healthcare provider for the purpose of the evaluation. 

I understand that the healthcare provider to whom I am referred is responsible for all medical advice and treatment. I acknowledge my right to seek a second opinion or explore alternative treatment options.

I acknowledge that any offer on TFD’s part to cover the cost of the medical evaluation is a charitable act, and that TFD is not assuming any liability for the evaluation or subsequent treatment.

By signing below, I confirm that I have read and understood the information provided in this consent form, and I voluntarily consent to the referral for a medical evaluation, with costs potentially covered by TFD.

TFD’s Health Initiatives staff are not credentialed providers and therefore cannot make a medical referral to any treatment provider or referral partner. TFD’s staff members meet with each participant for a discovery call, illuminating their specific health and wellness issues, and providing them understanding of some of the possible treatment options. If the participant is interested in exploring one of these treatment options, TFD staff will connect them to a referral partner or provider with the understanding that the credentialed provider is the competent authority to decide whether the participant is a good candidate for the provider’s specific intervention. Prior to any treatment, the provider and Task Force Dagger will have an initial agreement on potential cost and financial responsibility if the participant is a good candidate and agrees to undergo the course of treatment.