Esports Healthcare Consent

Please fill out the information below prior to your first visit with a provider at Esports Healthcare. This information is required. You cannot be seen by a provider if you have not submitted this information.

  • Date Format: MM slash DD slash YYYY
    Please select today's date.
  • Please fill out your full, legal first and last name (no nicknames).
  • Date Format: MM slash DD slash YYYY
    Please fill out or select your date of birth (mm/dd/yyyy).
  • Please fill out your current residence (no mailing-only or PO Box).
  • Please fill out a contact email.
  • NameRelationshipContact phone 
    Please provide an emergency contact in the event that we need to reach someone on your behalf.
  • Your full name (signature)Date (mm/dd/yyyy) 
    Please type your name. This is your digital signature. Please review consent options below.
    By checking this box, you confirm and authorize your digital signature to be used in place of a handwritten signature.
    I have read and understand Esports Healthcare's Consent To Treat
    I have read and understand my rights regarding HIPAA. A full copy of Esports Healthcare's HIPAA form can be found here.

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