Patient Registration

"*" indicates required fields

Patient Information

Patient Legal Name*

Today’s Date

MM/DD/YYYY

Social Security #

Sex

Phone*

Email*

Address

Street Address Address Line 2 City State ZIP Code

Can confidential messages be left on your voicemail?

Emergency Contact

Name

Phone

Relationship

Do they have HIPPA Access?

Authorization For Treatment

I authorize the staff at Mobile Quick Care & DOT, LLC to provide medical care as needed and access prescription history. I understand that I am responsible for payment for services rendered to me by Mobile Quick Care & DOT at time of service. I understand that services cannot be provided to a minor without the presence of a parent/legal guardian.

Signature

Telehealth Consent Form

I hereby authorize Mobile Quick Care & DOT, LLC to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing my medical condition. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as intended. I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.

Signature

Patient Consent for Use and Disclosure of Protected Health Information (PHI)

I hereby give my consent for Mobile Quick Care & DOT, LLC to use and disclose my PHI about me to carry out treatment, payment, and health care operations. With this consent, Mobile Quick Care & DOT may call my listed phone number and leave messages such as appointment reminders and calls pertaining to my clinical care. The staff may also send emails with appointment reminders, patient statements and/or any items that assist the practice in carrying out health care operations.

May we discuss your medical condition with any family members?

If YES, please provide the full name of the individuals allowed.

Authorization/ Consent for Treatment of a Minor

Please complete the following if the medical services will be provided to a minor under the age of 18.

I hereby authorize Monica Buie, APRN, to administer medical examinations and treatment deemed necessary for the following minor.

Parent/Guardian Name

What is your relationship to this minor?

Date of Birth

MM/DD/YYYY

Parent/Guardian Signature

This field is for validation purposes and should be left unchanged.