Concierge Assisted Intake

Consent & Releases

Please review and acknowledge the following consent forms. All are required to proceed.

Consent to Treatment

I consent to receive healthcare services and treatment from this organization. I understand that:

  • I have the right to accept or refuse any treatment or procedure
  • My healthcare information will be protected according to HIPAA regulations
  • I may withdraw consent at any time in writing
  • Emergency treatment may be provided when necessary

Release of Information

I authorize the release of my medical information as needed for my care. This includes:

  • Sharing information with healthcare providers involved in my care
  • Submitting claims to my insurance company
  • Coordinating care with other medical facilities when necessary
  • Fulfilling legal and regulatory requirements

Note: These consents are required to receive care. If you have questions about these forms, please ask your care team before proceeding.