This form will be sent via standard, unencrypted email to the practice. Please exercise caution and do not include any confidential information on this form. Note that submitting this form is not intended to create a therapist-client or doctor-patient relationship. Practitioners should contact you and initiate a formal intake process if they plan to work with you as a client.
By clicking "Submit," you acknowledge this form will be sent to Morgan Counseling and Consulting PLLC in the manner described above.
By clicking 'continue', you are consenting to all F.S.R.O. Terms & Conditions subject to termination upon violation.
You are responsible for taking steps to protect yourself from unauthorized use of online communication, such as keeping your password confidential. eClinicalWorks is not responsible for breaches of confidentiality caused by you or an independent third party. You agree to not engage in any illegal online communication. Access to Online Communication The following pertains to access to and use of online communication: Online communication does not decrease or diminish any of the other ways in which you can communicate with your provider. It is an additional option and not a replacement. eClinicalWorks may stop providing online communication or change its services at any time without prior notification to you. Risks of Using Online Communication All medical communication carries some level of risk. While the likelihood of risks associated with the use of online communication, particularly in a secure environment, is substantially reduced, the risks are nonetheless real and very important to understand. It is very important that you consider these risks each time you plan to communicate with your physician, and communicate in such a fashion as to mitigate the potential for any of these risks. These risks include, but are not limited to: Online communication may travel much further than you planned. It is easier for online communication to be forwarded, intercepted, or even changed without your knowledge. Online communication is easier to falsify than handwritten or signed hard copies. A dishonest person could attempt to impersonate you to try to get your medical records. It is harder to get rid of an online communication. Backup copies may exist on a computer or in cyberspace, even after you have deleted your copies. Online communication is not private simply because it relates to your own medical information. Employers and online services have a right to inspect and keep online communication transmitted through their systems. Online communication is also admissible as evidence in court. Online communication may disrupt or damage your computer if a computer virus is attached. Patient Acknowledgement and Agreement I acknowledge that I have read and fully understand this consent form. I understand the risks associated with online communication between my physician and me, and consent to the conditions outlined herein. In addition, I agree to follow the instructions set forth herein, as well as any other instructions that my physician may impose to communicate with patients via online communication. I have had a chance to ask any questions that I had and to receive answers. I have been proactive about asking questions related to this consent agreement. All of my questions have been answered and I understand and concur with the information provided in the answers.
In consideration of your use of the Services, you agree to (a) provide accurate, current and complete information about you as may be prompted by any registration forms on or through the Services or otherwise requested by F.S. ROsvs (“Registration Data”); (b) maintain the confidentiality and security of your password and identification and agree to accept responsibility for all activities that occur with your permission under your account or password; (c) maintain and promptly update the Registration Data, and any other information you provide to F.S. ROsvs, to keep it accurate, current and complete; (d) promptly notify F.S. ROsvs regarding any material changes to information or circumstances that could affect your eligibility to continue to use the Services or the terms on which you use the Services; and (e) be fully responsible for all use of your Account and for any actions that take place using your Account.