****Notice of Acquisition ** TBD Health Inc. was recently acquired by Wisp, Inc. As such, all applicable references to TBD HEALTH INC. or “we”, “us”, or “TBD Health” shall now be "Wisp, Inc." below.**

Identity Verification & Truthfulness Consent

I verify that I am the patient and that I have answered the questions asked in this intake form. I verify that the name and date of birth provided are accurate. I confirm that I have reviewed and understood all the questions asked of me. I attest that the answers and information I have provided in this questionnaire are true and complete to the best of my knowledge.

I understand that it is critical to my health to share complete health information with my doctor. I will not hold the doctor or affiliated medical practice responsible for any oversights or omissions, whether intentional or not, in the information that I provided.