Master Consent — Tiers 2–4

This single consent covers the Tier 2 questionnaire, Tier 3 lab entry, and (optionally) Tier 4 physician review. You may revoke consent at any time. Use your Patient ID instead of your full name if you prefer.

Your Info

Patient ID (recommended)

Email (optional)

What You Consent To

1) Tier 2 — Questionnaire & Data Handling

We collect your symptom responses and compute weighted scores aligned to Walsh biotypes. Identity is optional; a Patient ID is encouraged.

I consent to the collection and processing of my Tier 2 questionnaire responses.

2) Tier 3 — Lab Values & Correlation

You may enter lab values (e.g., Walsh Lab Panel; Methylation Panel). If you order labs or a consult via Second Opinion Physician (SOP), payment records there can be correlated with your Patient ID here.

I consent to the storage of my self‑entered lab values and correlation with SOP orders I place.

3) Tier 4 — Optional Physician Review

If you choose physician review, you authorize the physician to view your questionnaire, labs, and report, and to contact you.

I consent to physician review of my data and to being contacted for Tier 4 services (only if I purchase Tier 4).

4) Optional: TAO AI Analysis (De‑identified)

We may process de‑identified data to improve clarity of summaries and confidence indicators. You can opt out.

I consent to de‑identified analysis of my data for summary generation and quality improvement.

5) Optional: BSV Anchoring & Wallet

We may anchor cryptographic receipts of your reports on BSV; health data remains off‑chain. When available, you may connect a wallet for anonymous payments.

I consent to BSV anchoring of document receipts and understand my health data is stored off‑chain.

Acknowledgements

WalshDoc separates identity from clinical data wherever feasible.
You may request access, correction, or deletion (subject to legal/recordkeeping limits).
You may revoke consent at any time for future processing.
This platform provides education and assessment; physician advice applies only if you engage Tier 4 or a consult.

Signature

Full Name or Alias

Date

I affirm that I am the person identified above or an authorized guardian and that I understand and agree to this consent.

Printing saves a PDF in most browsers. “Agree & Save” downloads a text receipt for your records; you may upload it later if needed.