Forms & Policy

Prepare for Your Visit

We want your experience at Luckycharm Primary Care PLLC to be as smooth as possible. Below you’ll find downloadable forms and important patient policies to review before your visit.

Downloadable Forms

New Patient Registration Form

Medical History Questionnaire

Insurance & Consent Form

HIPAA Privacy Acknowledgment

Download All Forms (PDF)

Please bring completed forms to your first appointment or arrive 15 minutes early to fill them out in the office.

Key Patient Policies

Patient Age Requirement:
We serve adults 18 years and older only. Pediatric medical  services are not offered at this clinic at this time .

Insurance & Payment Policy:
Copays are due at the time of service. We accept most major insurance plans and self-pay patients.

No-Show & Cancellation Policy:
We require 24 hours’ notice for appointment cancellations. Repeated no-shows may result in a fee.

Privacy Policy:
We comply fully with HIPAA regulations to protect your personal health information. [View our full HIPAA policy →]

Privacy Policy

Luckycharm Primary Care PLLC  (“we,” “us,” “our”) respects your privacy and is committed to protecting your personal information. This Privacy Policy explains how [Brand Name] collects and uses information about you [when you opt-in to receive SMS messages from us]. 

Information We Collect [review and delete anything that is inapplicable or add other data that may be collected] 

When you opt-in to receive SMS messages, we collect:

  • Your phone number
  • Consent to send SMS messages
  • Your email address 
  • Your basic contact information 
  • Your messaging history 
  • [Other information you collect about individuals who visit your website or who interact with you in other ways]

 

How We Collect Your Information

We may collect your information directly from you, such as when you complete a form or contact us; automatically, such as when you interact with our website; or from others, such as when we receive information about you from third parties.

How We Use Your Information

We use your information to:

  • Send you the SMS messages you’ve opted in to receive
  • Provide updates, promotions, or other relevant content based on your preferences
  • Choices and Controls
  • To operate our business 
  • [Other uses of the information that you make]

 

Disclosures of Your Information

We may disclose your information to our affiliated companies; to third party service providers, business advisors, or consultants who provide services to us; in connection with a merger, acquisition, reorganization, restructuring, financing transaction, or sale of assets; as required by law or administrative order; to assert claims or rights or to defend against claims; and [other disclosures you make]

Protection of Information

We take steps to protect your information against unauthorized use or disclosure. 

Updates

We may periodically update this privacy policy. If we make material changes that have a substantive and adverse impact on your privacy, we will provide notice on this website before the change becomes effective. We encourage you to periodically review this page for the latest information about our privacy practices.

How to Contact Us 

You can reach us by texting the word HELP for support to [number]. You may also contact us directly at [Insert an email and/or a toll-free number]

Other information that may be included in Privacy Policies

Depending on your jurisdiction and your business activities, you may need to include provisions on additional topics, including:

  • The category of personal data you collect, and whether each category is disclosed, sold, or shared;
  • The Sale or Sharing of  personal information

We do not share your personal information, phone number, or SMS consent opt-in data with third parties or affiliates for marketing or promotional purposes.

  • Information about how you use cookies;
  • Information about how you handle the personal data of children;
  • Information about how individuals can exercise their privacy rights (e.g., to access, correct, or delete their data); and
  • Whether your website responds to do not track or global privacy control signals.

Terms and Conditions

By opting in to receive SMS messages from Company (“we,” “us,” “our”), you agree to these Terms and Conditions (Terms).

SMS Messaging Service

By providing my phone number, I consent to receive SMS text messages from Company for appointment reminders, marketing messages, and general two-way communication about your relationship with Company. Message and Data Rates may apply.

Message Frequency

You will get more than one message from us unless you opt-out, and while messaging frequency varies, you will likely receive messages pertaining to your account with us as you request, or up to 4 messages per month. Company reserves the right to alter the frequency of messages at any time to increase or decrease the total number of messages. Company and carriers are not liable for delays or undelivered messages.

Message and Data Rates

Message and data rates may apply based on your mobile carrier’s terms.

Privacy Policy

Your information will be handled in accordance with our Privacy Policy which you can find on our website

Cancellation/Opt-Out Instructions

You can opt out of receiving SMS messages at any time by replying STOP to any message we send you. After you opt out of text messaging, you will receive one additional message confirming your request has been processed. 

Help/Customer Support

Text the word HELP for support. You may also contact us directly at the number listed on our website for our main office.

Liability

We are not responsible for any charges, errors, or delays in SMS delivery or undelivered messages caused by your carrier or third-party service providers.

Note: Certain businesses, such as healthcare providers, may include additional terms, including the risks of sending and receiving health information subject to HIPAA via text message, the rules about sending text messages to the provider’s office, and what to do if the subscriber is experiencing a medical emergency.