New Treatments - His Clinic

New Treatments 🥳

We are about to launch a whole range of exciting new treatments…

We will need the information below for verification purposes and to provide you with the best pricing for the new treatments and services we will offer.

We know your time is valuable- we will send you a $20 discount code once your Medicare details have been verified successfully.

Please Provide:

Name*
First Last
Date of Birth*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Your Medicare Number*
Your Position on the Medicare Card*
Consent*
Telehealth Consent Form Health Care Services 1. I hereby authorize Health104 Medical Clinic to use the telehealth practice platform for telecommunication for evaluating, testing and diagnosing of my medical condition. 2. I understand that technical difficulties may occur before or during the telehealth sessions and my appointment cannot be started or ended as scheduled 3. I accept that the professionals can contact interactive sessions with video call; however, I am informed that the sessions can be conducted via regular voice communication if the technical requirements such as internet speed cannot be met. 4. I understand that my current insurance/Medicare may not cover the additional fees of the telehealth practices and I may be responsible for any fee that my insurance/Medicare does not cover. 5. I agree that my medical records on telehealth can be kept for further evaluation, analysis and documentation, and in all of these, my information will be kept private.