Consent for Treatment

Please indicate your approval and understanding before starting your Fort HealthCare e+Care visit with a Fort HealthCare health care provider.

I ACKNOWLEDGE THAT Fort HealthCare e+Care IS NOT DESIGNED OR INTENDED OR APPROPRIATE TO ADDRESS SERIOUS, EMERGENCY, OR LIFE-THREATENING MEDICAL CONDITIONS AND SHOULD NOT BE USED IN THOSE CIRCUMSTANCES.

I acknowledge that I will answer questions truthfully and that if I do not understand a question I will stop using Fort HealthCare e+Care.

I acknowledge that I am a resident of AND located in the State of %{visit_eligibility_state} at the time I start this visit.

I understand and acknowledge that my Fort HealthCare e+Care will establish a clinician patient relationship and that my visit information will result in the creation of a medical record of Fort HealthCare.

I acknowledge that I have agreed to the Terms of Service and I understand the Privacy Policy.

Consent for treatment:

I will have a chance to discuss and / or refuse the care recommended by my Fort HealthCare e+Care provider. Fort HealthCare e+Care providers cannot promise specific results. To provide this care, my Fort HealthCare e+Care provider will rely on information I provide about my health, including genetic information such as family health history.

Electronic health record:

I understand that Fort HealthCare e+Care uses electronic health records, which allow providers using this record to store, update and use my health information when needed at the time I am seeking care. The electronic health record allows better access to my health information.

I acknowledge that any provider who uses the electronic record may access and use my health records as needed to provide treatment (including coordinating my care).

For more information on how your medical information may be used and disclosed and how you can get access to this information, please see the Fort HealthCare NOTICE OF PRIVACY PRACTICES.

My consent for treatment will remain valid until I revoke (withdraw) it in writing or until the law states it has expired. Any records created prior to this withdrawal of consent will be maintained by Fort HealthCare e+Care for a period defined by Fort HealthCare and/or Fabric Labs, Inc.

I may get help with this process at any time by contacting Fort HealthCare e+Care at (920) 234-8998.

NOTE:You may access your medical record through Fort HealthCare e+Care at any time.

By signing this form, I consent to and authorize the Fort HealthCare e+Care provider to assess and recommend treatment if necessary.