I acknowledge that I have been informed of Qlinicare’s Notice of Privacy Practices, which explains how my medical information may be used and disclosed.

I understand that my protected health information (PHI) may be used for:
* Treatment and coordination of care
* Payment for services
* Healthcare operations

I understand that Qlinicare is required by law to:

* Maintain the privacy and security of my health information
* Provide me with notice of its legal duties and privacy practices
* Notify me in the event of a breach of my unsecured health information

I understand that:

* I have the right to access and request a copy of my medical records
* I may request corrections to my information
* I may request restrictions on certain uses or disclosures

I acknowledge that I have the right to request a copy of the full Notice of Privacy Practices at any time.

I understand that Qlinicare operates as a self-pay practice.

I agree that:

* Payment is required prior to services
* My payment covers the services outlined at the time of purchase
* No insurance billing will be submitted on my behalf

I acknowledge:

* Fees are non-refundable unless otherwise stated

I consent to receive medical care and treatment from Qlinicare. I understand that medical care may include evaluation, diagnosis, treatment, and follow-up care.

I acknowledge that:
* The practice of medicine is not an exact science
* No guarantees have been made regarding the outcome of my care
* I have the right to ask questions about my treatment

I authorize Qlinicare to provide care as deemed medically appropriate.

I consent to receive communication from Qlinicare via:

* Phone calls
* Text messages
* Email

These communications may include:
* Appointment reminders
* Care instructions
* Follow-up messages

I understand that standard messaging and data rates may apply.

I understand that my care may be provided via telemedicine, which involves electronic communication.

I acknowledge:
* Telemedicine may have limitations compared to in-person visits
* There may be risks such as technical issues or interruptions
* My privacy will be protected in accordance with applicable laws

**I consent to receive care via telemedicine**

I understand that my health information will be used for treatment, payment, and healthcare operations.
I acknowledge that Qlinicare will take reasonable steps to protect my personal health information.

I have read and agree to the terms above and understand that my personal and medical information will be kept confidential and used only for treatment, payment, and healthcare operations in accordance with privacy laws.