PATIENT AGREEMENT MATTHEW HADEN MD, LLC d/b/a MODERN MOBILE MEDICINEPatient Agreement • November 25th, 2020 • Virginia
This is an Agreement entered into on , 20 , between Matthew Haden MD, LLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company (Modern Mobile Medicine, Us or We), and (Patient or You).
PATIENT AGREEMENTPatient Agreement • March 26th, 2021 • Rhode Island
This is an agreement between DIRECT DOCTORS, Inc., a Rhode Island Professional Corporation, located at 2639 S County Trail East Greenwich RI (Direct Doctors), James Hedde, (Physician) in his capacity as agent of Direct Doctors, and you, (Patient).
AULIKE HEALTH PARTNERS LLC PATIENT AGREEMENTPatient Agreement • February 7th, 2022
I, , the parent/guardian of the above patient(s) have read and understand the following documents that were provided to me to review:
PATIENT AGREEMENTPatient Agreement • October 6th, 2020 • Arizona
The Practice, located at 9300 E Raintree Drive, Suite 2, Scottsdale, Arizona 85260, provides ongoing primary care services to its patients/members in a direct primary care practice model (DPC). In exchange for certain periodic fees the Practice agrees to provide the Patient with certain Services under the terms and conditions contained in this Agreement.
Patient AgreementPatient Agreement • April 8th, 2021 • Washington
This is an Agreement between Cornerstone Family Medicine, PLLC, located at 326 North Market Street, Washington, NC, (Cornerstone), and J. Wesley Earley, MD (Physician) in his capacity as an agent of Cornerstone, and you,
DIRECT PRIMARY CARE PATIENT AGREEMENTPatient Agreement • January 4th, 2021 • Idaho
PATIENT AGREEMENTPatient Agreement • December 26th, 2022 • Arizona
This is an Agreement entered into on ______________________ , 20 , between Thrive Life Center, an Arizona Professional Limited Liability Company (Practice, Us or We), and
Patient AgreementPatient Agreement • February 17th, 2021
PATIENT AGREEMENTPatient Agreement • December 31st, 2019 • Florida
This agreement (this “Agreement”) between MEGAN WEIGEL, DNP, L.L.C. d/b/a First Coast Integrative Medicine, a Florida professional limited liability corporation (“FCIM”), located at 14215 Spartina Court, Ste 200, Jacksonville, FL, 32224 and you, (the person signing below, referred to as “You”) is effective as of the date of Your signature.
PATIENT AGREEMENTPatient Agreement • January 21st, 2022 • Florida
Thisagreement(this“Agreement”) between MEGANWEIGEL, DNP, L.L.C. d/b/a First Coast Integrative Medicine, a Florida professional limited liability corporation (“FCIM”), located at 14215 Spartina Court, Ste 200, Jacksonville, FL, 32224 and you, (the person signing below, referred to as “You”) is effective as of the date of Your signature.
PATIENT AGREEMENTPatient Agreement • January 18th, 2021 • Texas
This is an Agreement entered into on , 20 , between Rockwall’s Gem MD, a Texas Professional Limited Liability Company (Rockwall’s Gem MD, Us or We), and
PATIENT AGREEMENTPatient Agreement • May 18th, 2021 • Tennessee
By your signature, you acknowledge that you are voluntarily becoming a patient of LifeMed Clinic. You also acknowledge this is a Membership Agreement between Lifestyle Medical Ministry, also known as LifeMed Clinic, a Tennessee 501c3 non-profit (Clinic, Us or We), and you (Patient or You).
Patient Agreement and Consent for TreatmentPatient Agreement • January 12th, 2017
Welcome to my practice. I am honored you have chosen me as your therapist and look forward to getting to know you during this time of growth and possibility. In order for our professional partnership to be most effective in meeting your needs and goals, it is important to begin with a clear understanding of expectations. The following information will better help you understand the therapy process, each of our rights and responsibilities, and my office policies. If you have any questions during or after reading this form, please discuss them with me.
Patient AgreementPatient Agreement • December 30th, 2023 • Arizona
The Practice, located at 5950 S COOPER RD STE 1 CHANDLER AZ, 85249 provides ongoing primary care medicine to its Members in a direct pay, membership model (DPC). In exchange for certain periodic fees, the Practice agrees to provide You with the Services described in this Agreement under the terms and conditions contained within.
PATIENT AGREEMENTPatient Agreement • March 20th, 2017 • South Carolina
This is an Agreement entered into on , 20 , between Verity Primary Medicine & Lifestyle, a South Carolina Limited Liability Company (Clinic, Us or We), and
PATIENT AGREEMENTPatient Agreement • October 27th, 2021
This direct primary care agreement is made between EHL Psychiatry LLC dba DreamCloud Psychiatry (“DreamCloud”), a Florida limited liability corporation, and you (“You” or “Patient”). DreamCloud agrees to provide Patient with Medical Services listed in this agreement in exchange for certain fees paid by you according to the terms and conditions described below.
Patient agreement to sharing informationPatient Agreement • April 2nd, 2012
Form issued by: Unit/Surgery Address Postcode Contact name Tel no. Patient Name Address Postcode D.O.B. NHS number Tel/mobile no. E-mail
PATIENT AGREEMENTPatient Agreement • September 22nd, 2021
We are required by federal and state laws to maintain the privacy of your child’s ‘Protected Health Information’, PHI. Your signature below indicates you have received a copy of the ‘Notice of Privacy Practices and Your Rights”, which describes how health care information about your child may be collected, used and disclosed for purposes of treatment or payment or for other specified purposes that are permitted and required by law. This notice also details how you may access this information.
Patient AgreementPatient Agreement • January 26th, 2022 • Hawaii
This agreement is between Deborah Ardolf, ND whose trade name is Dr. Ardolf & Associates, LLC. (hereinafter, “Physician” or “Dr. Ardolf & Assoc”), whose principal medical office is 54-2504 Kynnersley Rd., Kapaau, HI 96755 and you , whose mailing address is , and e-mail address is (the “Patient”).
PATIENT AGREEMENTPatient Agreement • March 29th, 2022
•I acknowledge and understand that the person listed below is voluntarily becoming a Member of The Doc Shoppe, PLLC and that this agreement is non-transferable.
PATIENT AGREEMENTPatient Agreement • November 27th, 2020
PERMISSION FOR EVALUATION AND TREATMENT: I hereby give permission to the professional staff of Pemi-Baker Community Health to perform any test(s) and give any treatment(s), deemed appropriate by the professional(s)
Patient AgreementPatient Agreement • December 4th, 2023 • Montana
The Practice, located at 6 East 9th Suite 302, Columbia Falls, Montana 59912, provides ongoing primary care to its Members in a direct pay care model (DPC). In exchange for certain periodic fees, the Practice agrees to provide the Member with the Services described in this Agreement under the terms and conditions contained within.
Patient Agreement and Consent for TreatmentPatient Agreement • June 25th, 2020
Welcome to Foundations Counseling. We are honored you have chosen us as and look forward to getting to know you during this time of growth and possibility. In order for our professional partnership to be most effective in meeting your needs and goals, it is important to begin with a clear understanding of expectations. The following information will better help you understand the therapy process, each of our rights and responsibilities, and our office policies. If you have any questions during or after reading this form, please discuss them with your clinician.
REHABILITATION THERAPY PATIENT AGREEMENTPatient Agreement • April 13th, 2022
Welcome to Liberty Hospital Rehabilitation Therapy. We are pleased that you have selected us as your provider of therapy. In order to best serve you, we ask that you take a moment to review and sign the following agreement. It explains our attendance and appointment cancellation policies. If you have any questions, we will be glad to answer them.
INTEGRATE INTERNAL MEDICINE COMPREHENSIVE WELLNESS - PATIENT AGREEMENTPatient Agreement • February 19th, 2023 • Idaho
This Patient Agreement (Agreement) is between Integrate Internal Medicine, P.C. (the Practice, Us or We), and (Patient, Member or You).
PATIENT AGREEMENTPatient Agreement • May 6th, 2021 • Florida
This is an Agreement between Fort Myers DPC, L.L.C., (“Fort Myers DPC”), a Florida professional corporation, located at 4755 Summerlin Rd, For Myers, 33919, Florida, Nadezhda Gonzalez MD and Kivit Lima MD, (collectively “Physicians” and singularly “Physician”) in their capacity as agents of Fort Myers DPC, and you, Patient (“patient” or “you”):
Patient AgreementPatient Agreement • March 12th, 2021 • South Carolina
This is an Agreement entered into on , 20 , by and between Pennington Primary Care, LLC, a South Carolina professional corporation, located at 197 Piedmont Blvd. Suite 110, Rock Hill, SC 29732 (Pennington Primary Care) and
PATIENT AGREEMENTPatient Agreement • April 14th, 2008
Office Practice/Clinic personnel at this facility are hereby authorized to administer any medical, diagnostic or therapeutic treatment, as may be deemed necessary or advisable. I have the right to consent or refuse consent, to any proposed procedure or therapeutic course, absent emergency or extraordinary circumstances.
PSYCHOTHERAPIST-PATIENT AGREEMENT/CONTRACTPatient Agreement • February 2nd, 2023
Welcome to my practice. This document contains important information about my professional services and business policies. Although these documents are long and sometimes complex, it is very important that you read them carefully. Please jot down any questions you might have about the procedures so that we can discuss them at that time. When you sign this document, it will represent an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be binding on me unless I have taken action in reliance on it; if there are obligations imposed on me by your health insurer in order to process or substantiate claims made under your policy; or if you have not satisfied any financial obligations you have incurred.
PATIENT AGREEMENT (Weight Management) Jan Hester MD PCPatient Agreement • October 29th, 2020 • Colorado
This is an Agreement entered into on , 20__, by and between Jan Hester MD PC, a Colorado professional corporation located at 1120 E. Elizabeth St, Building G, Suite 1, Fort Collins, CO 80524 (Jan Hester MD PC), Jan Hester MD (Physician), in her capacity as an agent of Jan Hester MD PC and (Patient).
PATIENT AGREEMENT FORMPatient Agreement • March 25th, 2021 • Florida
This is an Agreement between My Doc, L.L.C., a membership based Internal Medicine practice located at 721 South Orange Blossom Trail, Apopka, Florida 32703, and You (Patient) to receive medical services from a team of healthcare providers acting in their capacity as agents of My Doc, L.L.C.
PATIENT AGREEMENTPatient Agreement • September 16th, 2020 • Kansas
This is an Agreement entered into on , 20 , between Kansas City Direct Primary Care, a Kansas Limited Liability Company (Clinic, Us or We), and
EMPLOYER-SPONSORED PATIENT AGREEMENT KANSAS CITY DIRECT PRIMARY CARE, LLCPatient Agreement • April 20th, 2021 • Kansas
This is an Agreement entered into on / /20 , between Kansas City Direct Primary Care, a Kansas Limited Liability Company (Clinic, Us or We), and
PATIENT AGREEMENT DOCTOR DIRECT, LLCPatient Agreement • October 21st, 2021 • North Carolina
This is an Agreement entered into on , 20 , between Doctor Direct, LLC, a North Carolina Limited Liability Company (Clinic, Us or We), and (Patient or You).
PATIENT AGREEMENTPatient Agreement • May 15th, 2021 • North Carolina
This Patient Agreement (Agreement) is between Wellspring Direct Primary Care, PLLC (the Practice, Us or We), and (Patient, Member, or You).
