Complete & Compassionate OB/GYN
Care
Consent To Treatment
Please PRINT this form and BRING
it with you to your appointment.
Patient Name: ______________________________
Date of Birth: ____________________
Social Security No.: _________________________
Today's Date: ___________ Time: ________ am / pm
I, ________________________ (the
_________________ of __________________________), hereby voluntarily consent to
outpatient care at Complete & Compassionate OB/GYN Care, P.A., encompassing
routine diagnostic procedures, examination and medical treatment including, but
not limited to, routine laboratory work (such as blood, urine and other
studies), taking of x-rays, heart tracing and administration of medications
prescribed by the physician.
I further consent to the performance of those
diagnostic procedures, examinations and rendering of medical treatment by the
medical staff and their assistants, including nurse practitioners, physicians'
assistants, medical assistants, or their designees as is necessary in the
medical staff's judgement.
Release of Information: (a) I authorize
Complete & Compassionate OB/GYN Care, P.A. to release medical information
to third party insurance carriers for the purpose of filing insurance claims
related to my medical care. (b) I further authorize the release of medical
information about treatment here to my doctor or anyone designated by
me.
I understand that this consent form will be
valid and remain in effect as long as I receive medical care at Complete &
Compassionate OB/GYN Care, P.A.
This form has been explained to me and I fully
understand this Consent To Treatment and agree to its contents.
Comments:
_______________________________________________________________________________________
_______________________________________________________________________________________
Signature of Patient or Person Authorized to
consent for patient: _______________________________
Signature of Witness who explained the
contents of this "Consent to Treatment" form:
_______________________________
******************************************************************************************************************
If the patient is a minor or is unable to
consent, please complete the following:
Signature of Closest Relative or Legal
Guardian: __________________________________________
Relationship: _________________________ Witness to Signature:
_______________________________
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