Consent Form - ValleyCare Medical Clinic

Doctor or Nurse Practitioner Name: *

Patient Acknowledgement & Agreement:

Please read the above and fill out the fields below to acknowledge this agreement.

Patient name: *

First

Last

Patient address: *

mailing address: street, city, postal code

Patient home phone: *

if you do not have a home phone, typing N/A is sufficient

Patient cell phone: *

if you do not have a cell phone, typing N/A is sufficient

Preferred phone for contact: *

Email: *

Would you like the following (check which apply)? *

Preferred pharmacy: *

name & city of location

Date submitted & initials: *

Appendix

If email or text is used as the form of communication:

Conditions of using the services: