CLINIC VISIT - CURRENT PATIENTS

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

New Patients - Please use our NEW CONSULT FORM.

Thank you for using our DIGITAL VISIT app to help expedite and optimize your care. This application is to be used prior to your next visit.

Using our HIPAA compliant secure digital system will require an email account to verify your identity. The email address will also help us provide critical communications with you. If you do not have an email account, you may create one here: accounts.google.com/signup.

Email *

For accuracy, please complete within 24 hours prior to your visit.

AGREEMENT AND CONSENT OF DIGITAL SUBMISSION AND USE OF ELECTRONIC SIGNATURE

_____ ____ ___ __ _

I hereby agree and consent that any signature (including any electronic symbol or process attached to, or associated with, this form, contracts, documents or other record and adopted by me with the intent to sign, authenticate or accept such contract or record) hereto or to any other certificate, agreement or document related to this submission, and any contract formation or record-keeping through electronic means shall have the same legal validity and enforceability as a manually executed signature or use of a paper-based record-keeping system to the fullest extent permitted by applicable law, including the Federal Electronic Signatures in Global and National Commerce Act, the New Hampshire 2010 New Hampshire Statutes TITLE XXVII CORPORATIONS, ASSOCIATIONS, AND PROPRIETORS OF COMMON LANDS CHAPTER 294-E UNIFORM ELECTRONIC TRANSACTIONS ACT Section 294-E:7 Legal Recognition of Electronic Records, Electronic Signatures, and Electronic Contracts, or any similar state law based on the Uniform Electronic Transactions Act. I hereby waive any objection to the contrary.

I also verify that I will complete and provide all required documents prior to the initial clinic evaluation and management visit with Pain Specialty Group.

IF YOU DO NOT AGREE, PLEASE DO NOT PROCEED WITH THIS PROCESS.

I HAVE READ, UNDERSTAND AND ACCEPT THE TERMS AND CONDITIONS OF THE AGREEMENT AND CONSENT OF DIGITAL SUBMISSION AND USE OF ELECTRONIC SIGNATURE *

I AGREE

PLEASE TYPE YOUR FULL NAME FOR ACCEPTANCE OF THE TERMS AND CONDITIONS OF THE AGREEMENT AND CONSENT OF DIGITAL SUBMISSION AND USE OF ELECTRONIC SIGNATURE *

DEMOGRAPHIC INFORMATION

_____ ____ ___ __ _

FIRST NAME *

MIDDLE NAME OR INITIAL

LAST NAME *

PHONE NUMBER *

DATE OF BIRTH *

YYYY

YOUR AGE *

GENDER *

male

female

Other:

UPCOMING VISIT DATE *

Please provide your upcoming scheduled visit date

YYYY

Clear form

Never submit passwords through Google Forms.

This form was created inside of Pain Specialty Group. Report Abuse

Forms