I understand that filling out this form from Roman Empire Agency is not intended to create a doctor-patient relationship and that it’s merely used to provide information to Roman Empire Agency in order to determine whether I am a potential candidate for services. I also understand that in the future I may receive information from Roman Empire Agency through electronic means, including without limitation e-mails and text messages, that may or may not be subject to the Health Information Portability and Accountability Act (“HIPAA”) rules and regulations, as well as state and local laws related to the privacy of personal information. I understand that there are risks associated in receiving information in this format, but still agree to receive future information in this format, regardless of whether I establish a relationship with Roman Empire Agency.