Consent to Care and Treatment
I am presenting myself for diagnosis and treatment by this non-profit group, and I voluntarily consent to the rendering of such care including diagnostic procedures and medical treatment by its Clinical and Research Faculty or Students as may, in their professional judgement, be deemed beneficial or necessary. I acknowledge that no guarantees have been made to me as to the effect of any such examinations or treatment; I understand any special procedure or treatment involving appreciable risk will be explained to me by FSRG Clinical and Research Faculty or Students and that I may, at any time, discuss or decline such treatment. I authorise these healers to provide a copy of my record for this visit and reports of any tests during visits to my other professional care givers to encourage continuity-of-care.

I understand that with the increased use of electronic communication and technology relevant electronic patient information may be faxed, electronically viewed, or collected by those directly involved in my care, and I authorise release of such electronic information as required for my direct care and as proscribed by law for public health organisations.

I understand that, though all services provided directly by FSRG Clinical and Research Faculty or Students are free, I may, if I wish, supply goods or services or arrange to support this non-profit health endeavour in whatever way I may to continue their healing service for me and my community. I further understand that services not provided directly by FSRG Clinical and Research Faculty or Students are not free and I am financially responsible for those services.

Acknowledgement of Receipt of Consent to Care and Treatment *
In signing below, I affirm that I (1) have received a copy of the consent to care and treatment; (2) read and understand the consent; and (3) agreed to comply and be bound by the consent. If you do not agree, state 'NA'.
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Patient Name *
If the patient signed, state 'self'.
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Patient Date of Birth *
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Relationship to Patient *
If patient signed, state 'NA'.
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Reason for Refusal to Sign *
If not refused, state 'NA'.
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