Skip to main content
Skip to footer
Cerbo Clinic
INFO
CONTACT
NEW PATIENT (3)
Complete the consent below
Sign and date the form
Submit form, then continue to registration step (4)
INFORMED CONSENT
REG FORM (1) - POLICY CONSENT
Δ
Updates
Patient First Name
Patient Last Name
I UNDERSTAND AND AGREE WITH CERBO CLINIC HIPAA POLICY
Yes
No
I UNDERSTAND AND AGREE WITH CERBO CLINIC FINANCIAL POLICY
Yes
No
I UNDERSTAND AND AGREE WITH CERBO CLINIC COMMUNICATION POLICY
Yes
No
I GIVE PERMISSION TO CERBO CLINIC TO OBTAIN MY PRESCRIPTION HISTORY
Yes
No
I GIVE PERMISSION TO CERBO CLINIC TO USE MEDICAL SCRIBE TECHNOLOGY
Yes
No
Signature
Sign Here
Authorized Signatory - First Name
Authorized Signatory - Last Name
Date of Signature
Submit Signed Consent
PROCEED TO REGISTRATION (4)
English
Español de México
Deutsch (Sie)
Français
简体中文
Tiếng Việt
English
English
English
Español de México
Deutsch (Sie)
Français
简体中文
Tiếng Việt
English
English
Español de México
Deutsch (Sie)
Français
简体中文
Tiếng Việt
English 
Español de México 
Deutsch (Sie) 
Français 
简体中文 
Tiếng Việt