Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

Country

(###)

###

####

Identified Gender *

Female

Male

Other

Date of Birth *

MM

DD

YYYY

Name *

First Name

Last Name

Do you have a living will, power of attorney, or advanced directives? *

Yes

No

I'm not sure N/A

By selecting the box below, I acknowledge that I understand and/or agree to the following statement: *

I authorize Bee Better Wellness, LLC providers to provide treatment that they deem prudent and advisable for myself and, where applicable, my dependent(s). I understand that the services provided by Bee Better Wellness, LLC are voluntary and that I have the right to refuse treatment(s) before they are rendered. I understand that Bee Better Wellness, LLC does not provide emergency treatment and therefore will not seek such treatment. I understand that Bee Better Wellness, LLC does not replace my primary care provider (PCP) and that I must maintain an ongoing patient-provider relationship with my PCP. I understand that Bee Better Wellness, LLC will not authorize refills for medications being prescribed by other providers regardless of the urgency of said refills. I understand that Bee Better Wellness, LLC does not actively pursue prior authorizations (PAs) and that medications prescribed to me will be sought from compounding pharmacies. I authorize Bee Better Wellness, LLC to use photography to document treatment if deemed necessary. Furthermore, I authorize Bee Better Wellness, LLC to provide medical treatment through the utilization of telemedicine. In the event of technological failure, I understand that Bee Better Wellness, LLC may need to reschedule said appointment.

By selecting the boxes below, I acknowledge that I understand and/or agree to the following statement(s): *

Email: This policy is for patients who authorize Bee Better Wellness, LLC to communicate with them via a password-protected email that the patient checks at least three (3) times per week. Bee Better Wellness, LLC will only communicate electronically using the email address you have approved for communication. This email address will not be shared with any third party unless required for payment submission or in response to a legal subpoena. Bee Better Wellness, LLC cannot guarantee the privacy or security of any message sent via email. There is a potential risk for third-party interception of email communications.

Phone: I understand that the method of contacting the office, my provider, or any ancillary staff member must be through my phone number or by responding to an email sent by Bee Better Wellness, LLC. If a call is not answered, I will leave a clear and detailed voicemail including my full name, date of birth (DOB), and reason for the call. Bee Better Wellness, LLC will return calls within seventy-two (72) hours. Missed calls without a voicemail will not be returned

Social Media: I understand that social media platforms — including but not limited to TikTok, Facebook, Instagram, Twitter, and LinkedIn — are not acceptable forms of communication. These platforms cannot guarantee privacy or prevent interception; therefore, they will not be used by Bee Better Wellness, LLC for patient communication. Any attempts to communicate via social media will not be acknowledged.

Telemedicine: I authorize Bee Better Wellness, LLC to conduct telemedicine visits (“appointments”) via live Zoom video meetings. Zoom enables the patient to see and hear the provider in real time. If the telemedicine platform experiences technical issues, the provider will immediately attempt to contact the patient by phone to re-establish the connection. If reconnection is unsuccessful, the appointment will be completed via telephone or rescheduled at no additional cost to the patient. The patient agrees to download and test the application prior to the scheduled appointment. If the patient encounters technical difficulties on their end, they are expected to call Bee Better Wellness, LLC at my phone number for assistance. Signing in more than 15 minutes late will be considered a “no-show” and will be subject to a $25 rescheduling fee.

By selecting the box below, I acknowledge that I understand and/or agree to the following statement: *

I understand that it is my responsibility to schedule appointments in a timely-fashion and at the direction of the provider’s care. Furthermore, I understand that I will keep appointments that are scheduled at a future date and that cancellations must be done in more than forty-eight (48) hours ahead of a scheduled appointment. Failure to cancel an appointment in greater than forty-eight (48) hours ahead a scheduled appointment will result in a $25 cancellation penalty. Also, failure to keep scheduled appointments may result in not receiving prescriptions, testing, and/or other related care being delivered on time. I understand that if I have been subjected to a cancellation penalty that I must pay the balance of the penalty prior to be given an opportunity to schedule future appointments

I have read the aforementioned billing/financial responsibility agreement, the consent to treat agreement, the communication agreement, and the appointment policy agreement. I fully agree to all terms and conditions in the aforementioned agreements.

Signature *

First Name

Last Name

Today's Date *

MM

DD

YYYY

Opt-in Disclosure

By providing your phone number and submitting this form, you consent to receive text messages from BEE Better Wellness regarding customer service inquiries and appointment confirmations. Message frequency may vary based on your interactions. Message and data rates may apply. For assistance, reply HELP or contact 973-221-2665. To stop receiving messages, reply STOP. No further messages will be sent. For details, see our Privacy Policy: https://www.beebetterwellness.net/privacy-policy.