On Screen signature or
Send signed form
2. Create Account
3. Activate Account
If this is your first time attending our clinic, please enter your details for a faster first time check-in.
We use this information to create a new record in our system. Please note that completion of this form does not guarantee you service at our clinic. This just expedites the process.
If you have been to our clinic before and have registered your details with us, you do not need to complete this section, unless your address has changed.
I hereby consent to assessment and treatment at Spring Health (“SHC”) | Get Well Clinic (“GWC”) with Dr. Lai and Associates. I agree to participate in the medical assessments, and return for any necessary follow-up.
I understand and agree that the health care practitioners will assess and treat me to the best of their knowledge and abilities, in accordance with their training and qualifications. Due to the nature of medicine as not an exact science, I understand and agree that in rare circumstances, medical errors can occur. I agree to be a full participant in working with my healthcare provider to avoid any errors that may occur. If I am not confident of the care I am receiving, I understand that I am also free to get a second opinion on my own seeking. If I am not satisfied with the care that I receive, I will endeavor to communicate and work with my healthcare provider and staff at GWC to resolve any issues. If I am still not satisfied, I understand and agree that I am not obligated to stay, and that I am free to take my care elsewhere. I will endeavor to be courteous when I communicate with the doctors and office staff, and also when I relay my positive or negative experiences to others regarding the care I received.
I give consent and permission for Dr. Lai and his associates to communicate and exchange my personal and medical information with other members of my healthcare team for the purposes of managing my health. I understand that the electronic medical record at GWC is a common shared system among the associates of the clinic. I understand that only those health care providers who have an active role in treating me are considered part of my circle of care; and that they may have access to my records but limited to what is necessary in order to provide me with the care they are responsible for.
This consent form is NOT an authorization for releasing my medical records to a third party. However, I hereby understand that if I ever authorize my transfer of my medical records to third parties (such as insurance companies, lawyers, or designates), my records with potential sensitive and personal information may be included in the transfer. I understand that I may choose to withhold my records or redact portions of my transferred files, however, there will be a notice to the third party that the records transferred are incomplete. Furthermore, Spring Health Corp, Get Well Clinic, and Dr. Lai and Associates cannot be held responsible for who access the records once the records have left the office in the possession of an authorized individual.
Powered by ChronoForms - ChronoEngine.com
4. Pay for e-Platform