Name * First Name Last Name Email * Specific Need * Briefly describe your current healthcare navigation needs or challenges. Any specific goals or outcomes you hope to achieve? Phone (###) ### #### Service Interest * Which service are you interested in? Individual Consultation Corporate Consulting Public Speaking Preferred Communication Method Phone Email Text Video Call In-Person Additional Information Any relevant background or context that would be helpful to know? Consent and Agreement * 1. Privacy Policy Acknowledgment: I acknowledge that I have read and understand the [Your Company Name] Privacy Policy, which outlines how my personal information will be collected, used, stored, and protected. I consent to the collection and use of my information as described. 2. Terms of Service Agreement: I agree to Maverick Health Consultancy, LLC’s Terms of Service, including payment terms, cancellation policies, and the scope of services to be provided. I understand that I am responsible for any fees incurred and for providing accurate and up-to-date information for the effective delivery of services. 3. Confidentiality Agreement: I understand that any information I provide to Maverick Health Consultancy, LLC will be kept confidential and will not be shared with third parties without my consent, except as required by law. This confidentiality extends to all communication and documentation related to the services provided. 4. Liability Disclaimer: I acknowledge that the advice and services provided by Maverick Health Consultancy, LLC do not replace professional medical advice, diagnosis, or treatment. I agree that I am responsible for my own healthcare decisions and actions and that [Your Company Name] is not liable for any outcomes resulting from my use of their services. 5. Consent to Communication: I consent to receive communications from Maverick Health Consultancy, LLC regarding my services, appointments, and other relevant information via email, phone, or other contact methods I have provided. 6. Electronic Signature Consent: By checking this box and typing my name below, I agree that my electronic signature is the legal equivalent of my manual/handwritten signature. I consent to be legally bound by the terms and conditions of this agreement. Electronic Signature: [Type Name Here] Agree & Subscribe Agree Only Thank you!
