Room Share Agreement

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Practitioner Information & Room Use Agreement

* Indicates required field

Practitioner Name *

First

Last

Contact Number *

Email *

Mailing Address *

Line 1

Line 2

City

State

Zip Code

Country

1. Do you agree to conduct yourself in a punctual, responsible, and respectful manner toward fellow team members and all patients/clients? *

Yes No

2. Do you agree to maintain strict confidentiality regarding all information related to doctors, staff, and patients/clients? *

Yes No

3.Do you agree to follow the general policies, demonstrate a strong work ethic, and adhere to the rules established by GoodPoint Medicine? *

Yes No

4. Do you agree to use the space solely for services that are lawful and within the scope of your professional license and certifications? *

Yes No

5. Do you agree to hold GoodPoint Medicine and its staff harmless from any claims, liabilities, or damages arising from your own misconduct, malpractice, or professional negligence? *

Yes No

6. Treatment Room / Share Space Rules *

I acknowledge the following: (1) I may arrive up to 15 minutes before my scheduled time to set up the treatment room for my patients/clients. (2) I am responsible for resetting, vacating and returning the treatment room within 15 minutes after my scheduled time ends. (3) I will be held liable for any damage to the treatment room or common areas caused by myself, my clients, guests, or visitors. (4) GoodPoint Medicine and its staff are not responsible for any lost, stolen, or damaged personal items.

7. Late Fee & Cancellation Policy *

I agree to the following terms: (1) Room fees must be paid in full before setting up the treatment room for services. (2) Cancellations must be made at least 24 hours prior to the scheduled time. (3) A $20 late cancellation fee will apply for standard bookings canceled within 24 hours. (4) A $40 late cancellation fee will apply for full-day bookings canceled within 24 hours. (5) A $40 inconvenience fee will be charged for late room returns, payable to the next practitioner ($20) and GoodPoint Medicine ($20). (6) Repeated cancellations or late returns may result in suspension or permanent loss of room access.

8. Online/onsite Presence and Mutual Referral with GoodPoint Medicine Choose. Any *

I give permission for GoodPoint Medicine to share my professional contact information and headshot with their patients/clients. I am open to providing services to GoodPoint Medicine’s patients/clients upon request. I prefer not to participate in the above at this time.

CV/Resume *

Max file size: 20MB

Professional License / Certificate *

Max file size: 20MB

Additional License/Certificate *

Max file size: 20MB

A clear headshot of you *

Max file size: 20MB

Signed W9 Form If You Would Like to Perform Care to GoodPoint Medicine's Patients/Clients *

Max file size: 20MB

W-9 form Download
(https://www.irs.gov/pub/irs-pdf/fw9.pdf)

By submitting this form, I confirm that the information provided is accurate to the best of my knowledge, and I agree to be bound by the terms and conditions outlined in this Room Share Agreement. *

I agree.

Please ensure all required fields are completed before submitting the form.
Once submitted, you will be redirected to the Room Share Information and Booking Page.

Submit

West Orange Office Hours

Monday 9:30 am - 6:30 pm
Tuesday By appointment only
Wednesday 9:30 am - 6:30 pm
Thursday Closed
Friday 9:30 am - 6:30 pm
Saturday By appointment only

Woodland Plaza (280 Exit 8B)
155 Prospect Ave
Suite. 205
West Orange, NJ 07052
Tel: (973) 910-8288
Fax: (973) 910-8289

GOODPOINT MEDICINE PC
Hui-Tzu Yang, L. Ac., O.M.D.
(973) 910-8288 | [email protected]
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