General Consent Form

Patient Full Name *

Date of Birth *

Medical Record Number

I hereby consent to and authorize medical treatment by the healthcare providers at this facility.

I understand that:

1. Medical treatment may include, but is not limited to, examination, diagnostic procedures, treatment, and follow-up care.

2. The practice of medicine is not an exact science and no guarantees have been made regarding the results of treatment.

3. I have the right to ask questions about proposed treatments and to refuse any treatment.

4. My medical information will be kept confidential in accordance with applicable laws.

5. I am financially responsible for all charges incurred for services provided.

I consent to:

1. The performance of medical procedures as deemed necessary by my healthcare provider.

2. The use of anesthesia if required for procedures.

3. The presence of medical students or trainees during my care (for teaching hospitals).

4. Photography or video recording for medical documentation purposes.

5. Communication via phone, email, or text for appointment reminders and health information.

I consent to blood transfusions if deemed medically necessary

I consent to emergency medical care if I am unable to provide consent at the time

I consent to the release of my medical information to insurance companies for billing purposes

Questions or Concern

I have read and understand this consent form I confirm that I have had the opportunity to ask questions and that all my questions have been answered to my satisfaction. *

Printed Name *

Relationship to Patient *

Date *

Witness Name

L O A D I N G . . .

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Patient Information

Consent for Treatment

Additional Consents

Acknowledgment

Signature

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