PATIENT FORMS

Client Consent Form

Please complete this consent form before your first appointment. It covers specimen collection, HIPAA privacy practices, and financial responsibility. Everything is stored securely and referenced only by Aurelia clinical staff.

Client information

Required fields are marked with an asterisk.

FULL LEGAL NAME *DATE OF BIRTH *EMAIL *PHONE *STREET ADDRESS

CITY STATE ZIP

EMERGENCY CONTACT NAME EMERGENCY CONTACT PHONE

ALLERGIES OR RELEVANT MEDICAL CONDITIONS

This form is being completed for a minor under 18.

If checked, a parent or legal guardian must complete the fields below and sign on the minor's behalf.

Consents & acknowledgments

Please review each item carefully. The first three are required to proceed.

Consent for Specimen Collection & Concierge Services (required)

I voluntarily consent to the specimen collection, phlebotomy, point-of-care testing, CPR instruction, and related concierge wellness services provided by Aurelia Concierge Wellness Partners and its licensed personnel. I understand the routine risks (mild bruising, discomfort, lightheadedness, rare infection) and have had the opportunity to ask questions.

HIPAA Notice of Privacy Practices (required)

I acknowledge that I have been provided access to Aurelia’s Notice of Privacy Practices. I understand my protected health information (PHI) may be used or disclosed for treatment, payment, and healthcare operations, and only shared with third parties as permitted or required by law.

Financial Responsibility (required)

I understand that Aurelia collects payment before services are rendered through its secure Square point-of-sale system and also accepts Afterpay (buy-now-pay-later). Aurelia's concierge fees are separate from any laboratory or facility fees billed by third-party labs. I accept financial responsibility for services rendered and agree to Aurelia's posted cancellation policy.

Photography / Media Release (optional)

I grant Aurelia permission to capture non-identifying photography for internal training or marketing purposes. I understand this is optional and does not affect my care.

Electronic signature

Type your full legal name exactly as entered above. Your typed name serves as your legal signature under the Electronic Signatures in Global and National Commerce Act (E-SIGN).

TYPED SIGNATURE *DATE

A copy of your signed form will be emailed to you and stored securely on Aurelia’s protected records.