Patient Registration

I give Curogram, Vital Urgent Care and Pangea Laboratory LLC permission to conduct the requested diagnostic testing on my specimens.

I acknowledge that the information provided by me is true to the best of my knowledge. For direct insurance billing, I hereby authorize my insurance benefits to be paid directly to Pangea Laboratory LLC and Vital Urgent Care, and authorize them to release medical information concerning my testing to my insurer. I authorize Pangea Laboratory LLC, and Vital Urgent Care to be my Designated Representative for purposes of appealing any denial of benefits. I acknowledge and agree that Pangea Laboratory LLC, and Vital Urgent Care has the right to request additional medical records, such as consult notes, directly from my provider(s) for the purpose of insurance verification and proper billing. I also fully understand that I am legally responsible for sending Pangea Laboratory LLC and Vital Urgent Care any monies received from my health insurance company for the performance of any laboratory testing.

By signing, I acknowledge that I am at least 18 years of age or am the parent or legal guardian of the person who is registering for an appointment.

By signing I consent to the following: I agree to be treated via a video visit and acknowledge that I will be responsible for any relevant charges or copays depending on my insurance plan. I understand that this video visit is offered for my convenience and I am able to cancel my video visit for an in-person visit if I choose. I understand that a video visit may have limitations as the provider is not in the same room as me, and the provider may recommend that I be seen in person at any time during or after my video visit. I acknowledge that sensitive medical information may be discussed during this video visit and that it is my responsibility to locate myself in a location that ensures privacy and use a network connection that is private and secure. I acknowledge that technical problems are a possibility which can interrupt my video visit before it has been completed. I am responsible for having the capability of a secure connection and use a device that is either plugged in or battery powered to last the duration of my video visit. I acknowledge that I should not be participating in a video visit in a way that could cause danger to myself or to those around me (such as while driving). If my provider is concerned about the safety of myself and/or others around me, I understand that they have the right to terminate the visit. If you do not consent please contact your PCP or local urgent care for an in person visit. Signed: ____________________ Print: _____________________