Consent to Treatment Form - PatientNotes.ai

Practice Name: _______________________________________________

Address: _______________________________________________

Phone: _____________________ Fax: _____________________

Patient Name

Date of Birth

Date

GENERAL CONSENT FOR TREATMENT

I, the undersigned, hereby consent to and authorize the healthcare providers at this practice to perform medical examinations, diagnostic procedures, and treatments that are considered necessary or advisable for my care.

I understand that the practice of medicine is not an exact science and that no guarantees have been made to me regarding the results of any examination, treatment, or procedure.

I CONSENT TO THE FOLLOWING (check all that apply):

IMPORTANT NOTICE

I understand that I have the right to refuse any treatment or procedure. I understand that I may withdraw this consent at any time, except to the extent that action has already been taken in reliance on this consent. I have had the opportunity to ask questions and have received satisfactory answers.

PATIENT ACKNOWLEDGMENT

By signing below, I acknowledge that:

I have read and understand this consent form
I have had the opportunity to ask questions
I voluntarily consent to the treatments and procedures described above
I understand that this consent remains in effect unless I revoke it in writing

Patient Signature

Date

Time

Printed Name of Patient

If Minor, Parent/Guardian Name

Parent/Guardian Signature (if patient is a minor)

Relationship to Patient

WITNESS (Required for patients unable to sign)

Witness Signature

Witness Printed Name

Date

CONSENT TO TREATMENT

IMPORTANT NOTICE

WITNESS (Required for patients unable to sign)