Patient's Name:
Date of Birth:
Address:
Email address:
Phone number:
Full name:
Relationship with patient:
Contact number:
Consent Acknowledgment: I understand the nature of the proposed treatment/procedure, including the potential risks and benefits. I have had the opportunity to ask questions and have received satisfactory answers. I acknowledge that no guarantees have been made regarding the outcome of the treatment/procedure.
Privacy and Confidentiality: I understand that my medical information will be kept confidential and will only be disclosed as required by law or with my consent.
Financial Responsibility: I agree to be financially responsible for the cost of the treatment/procedure, including any co-pays, deductibles, and other charges not covered by my insurance.
Terms:
I, the undersigned, hereby authorize [Healthcare Provider's Name] and its designated medical staff to perform the following medical treatment or procedure.
Patient/Guardian Signature
Date