CONSENT FORM

First and Last Name

Email Address

Birthday (Month, Date, Year)

Contact Number

Allergies (list all reactions to medications, foods and other agents)

Past Medical History (What conditions have you suffered?)

Medications (List all prescriptions and non-prescription medicines, vitamins, home remedies, birth control pills, herbs, etc., its dose and frequency)

I consent to: I consent to: I hereby authorize and request iCareNewYork to render care management services to me. I understand that I am a participant in my care management plan and that the plan is an agreement. I understand that I have the right to refuse treatment or terminate services at any time by notifying iCareNewYork. I understand that iCareNewYork also reserves the right to terminate services at any time. I understand that iCareNewYork will inform me of the reason. This consent is intended as a waiver of liability for such treatment excepting acts of negligence. At any time, if iCareNewYork, its employees or assigns believe that I am in need of any medical emergency, I authorize iCareNewYork, or its employees to provide or obtain such medical emergency treatment as they deem advisable under the circumstances, and I agree to assume sole responsibility for all charges incurred in relation to such treatment. I further agree that if I choose to refuse any treatment or services that iCareNewYork, its employees or assigns deem advisable under the circumstances, and in the event of any medical emergency, I agree to assume sole responsibility for any outcome as a result of my refusal to accept treatment. I understand the legal impact of this document restricting iCareNewYork, personnel from providing or initiating heroic measures on my behalf.

Authorization: Authorization: I consent to a twelve (12) hour cancellation policy. If I cancel less than twelve (12) hours before the start of the shift, I will be charged a one (1) hour cancellation fee. There will be no fee if I cancel or change for cancelling a shift if iCareNewYork is given more than twelve (12) hours of advance notice.

Hoilday rates: Hoilday rates: I understand that services performed on the holidays listed below will be billed at 1.5 times the normal rate: New Year's Eve & Day, Easter Sunday, Memorial Day, Labor Day, Fourth of July, Thanksgiving, Christmas Eve & Day.

Agreement: Agreement: I have read and fully understood the content of this contract for services agreement form and agree to and authorize the foregoing.