Minor Consent to Treatment and Sharing of Medical Information with Parent or Guardian

Last Updated: July, 2023

(For Patient Age 13 and Over)

I voluntarily consent to the diagnosis, medical care and treatment provided through telehealth by First Opinion Health Services (FL) PLLC, First Opinion Health Services (IL), P.C., NY Medicine/Telemedicine, PLLC, First Opinion Health Services (NC), PLLC, First Opinion Health Services, Inc., First Opinion Health Services (TX), PLLC, First Opinion Health Services (GA), LLC, First Opinion Health Services NJ, LLC (“Curai Health”) that is considered necessary or recommended by my physician(s) and other healthcare providers in their professional judgment.

I understand that Curai also requires my parent or legal guardian to consent to my treatment and hereby authorize Curai Health to reach out to my parent or legal guardian by electronic means or telephone for purposes of securing his or her consent to provide healthcare services to me via telehealth modalities. I also consent to Curai Health sharing my medical information and records, including information about my treatment, with my parent or guardian. I further consent to the release of the relevant parts of my records so that my care can be paid for by my health plan or other responsible party.

I understand that I will have the opportunity to ask questions about my healthcare and treatment.

Note: If you do not feel comfortable with any of the terms set forth herein, you should not sign this Form, and should contact Curai Health at support@curai.com to discuss further.