Patient Intake and Consent Form Contact Us! Thank you {{patient_name_}} for submitting your Patient Intake and Consent Form information to HomeMD Health.We will contact you within 1 business day. Notice of ACO Participation Medicare Shared Savings Program ACO 11https://www.homemdhealth.com/wp-content/plugins/nex-formstruehttps://bestbuy.commessagehttps://www.homemdhealth.com/wp-admin/admin-ajax.phphttps://www.homemdhealth.com/consent-3yes1fadeInfadeOut Patient Intake and Consent FormPlease complete our online Patient Demographic Form to register yourself or your loved one for service with HomeMD Housecall Services. Once we receive your intake information along with the signed consent form, a referral specialist will contact you shortly thereafter (usually the same day) to coordinate for the first appointment with our provider staff. Patient Name Patient Date Of Birth Patient's Best Contact NumberHomeMD RepresentativePerson Assisting Patient with FormYes.I acknowledge that I received verbal and written information and explanation, if requested, regarding the following items below:Yes.I have read and understand the privacy policy *Yes.I have read the and understand the Terms & Conditions*Patient Intake FormConsent For ServicesChronic Care ManagementWound ConsentPatients or Advocates Signature of Consent Please flip your phone sideways when signing this form, For tablets, please refresh your browser to erase the signature. NO info will be lost.Type in Your Name Date of Consent : [wpdts item="date"]SUBMIT