Communication Consent Form (PI)

Please correct the errors described below.

Date of Birth

SELECT YOUR PROVIDER (2 options):

*If using your insurance, please include a picture of the front side of your card.

    Please upload a file

    NON-TRADITIONAL COMMUNICATION CONSENT:

    We use HIPAA-compliant technology to reduce wait times, improve the intake process, and ensure that you have access to your provider when needed. We need your consent in order to move forward. Your provider will explain each service in detail.

    Your information will be encrypted.

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