New Patient Agreement Acceptance

By completing this form, you are agreeing to the terms of the New Patient Agreement.

After completing this Acknowledgement, you will then be taken to the Living Matrix system where you will enter your health history.

A laptop or desktop computer is required. Living Matrix does not work with tablets or phones.

If you have any questions, please contact us at 913-642-1900.

Email Communication: When we send you an email, or you send us an email, the information that is sent is not encrypted. This means a third party may be able to access the information and read it since it is transmitted over the internet. In addition, once the email is received by you, someone may be able to access your email account and read it. However, email is a popular and convenient way to communicate for most people. The federal government has acknowledged this and provided guidelines that state if the patient has been made aware of the risks of unencrypted email, and the patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email. The federal government has acknowledged this and provided guidelines that state if the patient has been made aware of the risks of unencrypted email, and the patient provides consent to receive health information via email, then a health entity may send that patient personal medical information via unencrypted email.*
- I understand the risks of unencrypted email stated above. Dr. Klug and her associates MAY communicate with me by unencrypted email about treatment, payment and health care operations.
- I understand the risks of unencrypted email stated above. Dr. Klug and her associates MAY NOT communicate with me by unencrypted email about treatment, payment and health care operations.
Agreement Terms Acknowledgement:

This document is not a contract. It is specifies the arrangement between HealthSpan and you, our patient or guardian of a patient, at the time you sign the document. We periodically review this agreement or update it at our discretion. We do our best to notify our patients of changes to this agreement before their next appointment. Unfortunately, it is not always possible to notify you of changes immediately, and receipt of notification cannot be guaranteed.

As such, by signing below, you are acknowledging that you have read this document and agreeing that you will abide by terms stated therein, including any changes or additions we may make after the document is signed. You are also acknowledging that the document is not a contract and that we have the right to change anything in the document, as well as anything else referenced therein, at our discretion and without prior notice.
Consent*
I agree to the New Patient Agreement.
Patient, Parent or Guardian Name*
Email*
Date*
MM slash DD slash YYYY
Signature*
Phone
This field is for validation purposes and should be left unchanged.

New Patient Agreement Acceptance

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