Virtual Services Registration Form

Thank you for your interest in joining our virtual services program. Mary's Place by the Sea welcomes women diagnosed with any type of cancer, either in treatment or post-treatment. NOTE: this guideline applies to Virtual Guests ONLY.

PRIVACY NOTICE: We respect your privacy and collect only that personal information we believe is necessary to schedule and accommodate your virtual session at Mary's Place by the Sea. For further details about our privacy practices applicable to your access or use of our website, please see our Privacy Policy.

New Account

Diagnosis and Treatment Details

Please note that Mary’s Place by the Sea is not a medical facility with medical staff and does not provide medical treatment or diagnosis. Accordingly, participating in the virtual services being offered by Mary’s Place by the Sea does not constitute “telehealth” or “telemedicine” services as defined by New Jersey law or similar laws.

We request basic information regarding your diagnosis and treatment to help us better provide services to you and make any referrals, if needed or requested. Please refer to the Privacy Notice at the beginning of this form.

Emergency Contact Information

Important Notices, Waiver and Release

By accepting the services of Mary’s Place by the Sea, I (the undersigned person) acknowledge and agree that I am voluntarily accepting the services of Mary's Place by the Sea, that there are risks associated in engaging in the services that may be recommended by Mary's Place by the Sea and/or its staff, and that I will not engage in any activity that is not advised by my health care professional or where I feel I am not able to safely participate and that I, on behalf of myself, family, heirs, assigns, and all others acting on my behalf, RELEASE AND HOLD HARMLESS MARY'S PLACE BY THE SEA AND ITS OWNERS, PRINCIPALS, EMPLOYEES, AGENTS AND REPRESENTATIVES (“RELEASEES”) FROM ANY AND ALL INJURIES, DEATH, CLAIMS AND/OR LIABILITIES WITH RESPECT TO PERSONS OR PROPERTIES THAT MAY ARISE FROM MY PARTICIPATION IN THE SERVICES OFFERED BY MARY'S PLACE BY THE SEA, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, TO THE FULLEST EXTENT PERMITTED BY LAW. I understand that I may withdraw from receiving the services of Mary’s Place by the Sea at any time after signing and submitting this form.

I also understand that Mary’s Place by the Sea may refer me to third-party health care providers, for example licensed counselors or social workers, for additional medical services, including counseling, treatment or diagnosis. You will separately need to accept services from these providers according to their independent procedures. Any such referrals are made solely for your convenience and should not be taken as any type of endorsement of the quality of their services or as any type of representation as to the suitability of that provider to care for your particular needs. Should you choose to accept a referral, you agree that you will make your own assessment of the provider to serve your needs or, as appropriate, that you will rely upon the advice of your doctor or other health care professional and THAT YOU WILL NOT HOLD MARY'S PLACE BY THE SEA, ITS OWNERS, MANAGEMENT, OR EMPLOYEES RESPONSIBLE OR LIABLE FOR ANY LOSSES OR DAMAGES related to the referral.

YOUR AGREEMENT AND SIGNATURE: Please provide your full name below to act as an electronic signature. By adding your name below (and confirming your primary phone number) and submitting this form to Mary’s Place by the Sea you are expressing your intent to enter into a binding agreement with Mary’s Place by the Sea with the terms and conditions stated above. By signing, you also confirm that you have provided accurate information within this form.