Patient Agreement

 


YOUR HEALTH MATTERS! It’s a partnership where YOU need to take responsibility for YOUR OWN HEALTH. I look forward to helping YOU LIVE YOUR OPTIMAL LIFE!

Patient Agreement

1.     I want to get better, and I believe that I can and will!

 

2.     I will look at the Wellness Plan that is emailed (or given) to me. I will do my best to follow Dr. Gold’s instructions and I understand I can text her at 813-468-0905, in case of a problem.

 

3.     I understand that I need an appointment for any refill requests, lab orders, or prescriptions, to review labs or complete any form, or for any other medical reason, (even if I change insurance or use another laboratory company). This is for safety reasons, and because this will require Dr. Gold’s time.

 

4.     I understand that I can make my own appointments from the website at www.dgoli.com.

5.     I understand there is a $50 cancellation fee if I cancel my appointment less than 24 hours before the appointment, or if I do not show up for my appointment (except in the case of an emergency, hospitalization).

6.     When I come in only for a lab review, I will check that my lab results are back two days before the appointment, and bring in a copy of the lab report to the appointment if I can. If results are not back, I will reschedule my appointment (this can be done by finding the Calendly confirmation email).  I will keep the appointment if I need refills or to follow up for medical condition(s).

 

7.     I understand that the cost of the visit is $75 every 15 minutes and that I can use my HSA/HRA credit card, care credit, credit card, or cash.

 

8.     I have read, understand, and agree to the above agreement.

 

_____________________   __________________   _______________

Patient Name                      Patient Signature                  Date

Thank YOU!! J With warmest wishes, Tanya Gold, MD

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