Welcome to 24/7 Urgent Care!
Email address *
Full Name *
Date of Birth *
Home Address including Zip Code *
Phone Number *
Email *
Main Health Concern Today *
Past Medical History *
Past Surgical History *
Past Surgical History *
Family History *
Alcohol, Smoking, Drug History *
Emergency Contact Name, Phone, Relation *
Preferred Pharmacy including Address *
I understand that I have the following rights with respect to telemedicine or home urgent care. 1. I have the right to withhold or withdraw consent at any time without affecting my right to future care or treatment nor risking the loss or withdrawal of any program benefits to which I would otherwise be entitled. 2. The laws that protect the confidentiality of my medical information also apply to telemedicine. As such, I understand that the information disclosed by me during the course of my therapy is confidential. However, there are both mandatory and permissive exceptions to confidentiality, including, but not limited to reporting child, elder, and dependent adult abuse; expressed threats of violence towards an ascertainable victim; and where I make my mental or emotional state an issue in a legal proceeding. *
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