I, , voluntarily authorize GAIA Health PLLC and its licensed healthcare providers to perform the treatment or service(s) listed above.
I understand that the nature of my treatment, its intended benefits, potential risks, possible side effects, and available alternatives have been explained to me in a manner that I understand. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction.
I acknowledge that no medical treatment or procedure can guarantee a specific outcome, and I understand that individual results may vary. I understand that I may decline or discontinue treatment at any time, subject to appropriate medical advice.
I certify that the health information I have provided is true and complete to the best of my knowledge and that I have disclosed any significant medical conditions, allergies, medications, or other information that could affect my treatment.
By signing below, I voluntarily consent to receive the treatment or service(s) identified above from GAIA Health PLLC. I acknowledge that I understand the risks, benefits, and alternatives, and I authorize my provider to proceed with treatment. I also acknowledge that I have received sufficient information to make an informed decision regarding my care.
Electronic Signature Notice: I understand that my electronic signature has the same legal effect as my handwritten signature under applicable federal and Florida law.
