Consent for Treatment

Please indicate your approval and understanding before starting your Allina Health Online Questionnaire visit with a Allina Health Online Questionnaire health care provider.

I ACKNOWLEDGE THAT Allina Health Online Questionnaire IS NOT DESIGNED OR INTENDED OR APPROPRIATE TO ADDRESS SERIOUS, EMERGENCY, OR LIFE-THREATENING MEDICAL CONDITIONS AND SHOULD NOT BE USED IN THOSE CIRCUMSTANCES.

I acknowledge that I will answer questions truthfully and that if I do not understand a question I will stop using Allina Health Online Questionnaire.

I acknowledge that I am a resident of AND located in the State of %{visit_eligibility_state} at the time I start this online visit.

I understand and acknowledge that my Allina Health Online Questionnaire will establish a clinician patient relationship and that my online visit information will result in the creation of a medical record of Allina Health Online Questionnaire.

I acknowledge that I have agreed to the Terms of Service and I understand the Privacy Policy.

Consent for treatment:

I will have a chance to discuss and / or refuse the care recommended by my Allina Health Online Questionnaire provider. Allina Health Online Questionnaire providers cannot promise specific results. To provide this care, my Allina Health Online Questionnaire provider will rely on information I provide about my health, including genetic information such as family health history.

Electronic health record:

I understand that Allina Health Online Questionnaire uses electronic health records, which allow providers using this record to store, update and use my health information when needed at the time I am seeking care. The electronic health record allows better access to my health information.

I acknowledge that any provider who uses the electronic record may access and use my health records as needed to provide treatment (including coordinating my care).

For more information on how your medical information may be used and disclosed and how you can get access to this information, please see the Allina Health Online Questionnaire NOTICE OF PRIVACY PRACTICES.

My consent for treatment will remain valid until I revoke (withdraw) it in writing or until the law states it has expired. Any records created prior to this withdrawal of consent will be maintained by Allina Health Online Questionnaire for a period defined by Allina Health Online Questionnaire and/or Fabric Labs, Inc.

I may get help with this process at any time by contacting Allina Health Online Questionnaire at (612) 429-8214.

NOTE:You may access your medical record through Allina Health Online Questionnaire at any time.

By signing this form, I consent to and authorize the Allina Health Online Questionnaire provider to assess and recommend treatment if necessary.