Patient Portal YesNo
If yes, email:
2. I understand Shalom Health Care Center utilizes the following methods to contact me regarding my care and/or leave messages regarding my care via the following method(s): Text Message Email Telephone Call
3. I have completed the “Patient Registration Form” and (if applicable) “Patient Consent for Treatment of a Minor and/or Release of Information to Others” to the best of my ability and I request that information on those forms be included in my/my child’s health records.
4. I give my consent to be examined and/or treated by Shalom Health Care Center’s health care providers. I understand and agree that any in-depth examination and/or procedure will be explained to me before I give my consent.
5. All documents, policies, and procedures included in the Shalom Health Care Center intake process have been explained to me, and I understand that if I have any questions, I may ask a Shalom staff member at any time.
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Document Name: Patient Intake
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