New Patient Intake

The Longevity Society, LLC is required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices. We use and disclose your health information to provide your treatment, to obtain payment, and for our healthcare operations. We will not sell your information or use it for marketing without your separate written authorization. You have the right to inspect and request a copy of your record, to request corrections, to request restrictions on how we use your information, to request confidential communications, and to receive an accounting of certain disclosures. A full Notice of Privacy Practices will be provided at your first visit and is available on request.

I voluntarily consent to wellness evaluation and treatment by The Longevity Society, LLC and its licensed clinicians. I understand that services are provided by a board-certified Advanced Practice Registered Nurse, that no specific outcome has been guaranteed, and that I may refuse or discontinue any treatment at any time. I understand that the information I provide on this form is used to determine whether a treatment is appropriate for me, and that withholding relevant medical history may make treatment unsafe. This form does not itself establish a provider-patient relationship; that begins at my consultation.