Informed Consent | Healthcare Services

I understand the nature and scope of the healthcare services to be provided*

I acknowledge that I have been informed of the potential risks and benefits of treatment*

I understand my rights as a patient, including the right to refuse treatment at any time*

I accept financial responsibility for services not covered by my insurance*

I acknowledge receipt of the Notice of Privacy Practices (HIPAA)*

Will you be receiving telehealth services?*

Yes

No

Patient Full Name*

Electronic Signature (type your full legal name)*

Date*