CONSENT FOR TREATMENT AT SAVAGE FAMILY MEDICAL CENTER
I, [Patient Name], hereby consent to the medical treatment and care provided by the medical professionals at Savage Family Medical Center. This includes, but is not limited to, the following:
Assessment and Diagnosis: I consent to the evaluation of my condition through necessary exams, tests, and medical history review.
Treatment: I consent to any medical treatment, procedures, or interventions deemed necessary by the healthcare providers for my condition. This may include diagnostic tests, medications, and minor procedures.
Risks and Benefits: I have been informed of the possible risks and benefits associated with the proposed treatment, as well as any alternative treatments that may be available. I understand that the healthcare providers will take reasonable steps to ensure my safety.
Right to Refuse: I understand that I have the right to refuse any treatment or procedure, but that refusing treatment may result in an incomplete diagnosis or management of my medical condition.
Emergency Treatment: In case of an emergency, I understand that I may not be able to provide consent, and I consent to the necessary treatment to preserve my health and well-being.
Confidentiality: I acknowledge that my medical information will be kept confidential in accordance with privacy laws (such as HIPAA), and may be shared with relevant healthcare providers, insurers, or family members as needed.
Financial Responsibility: I acknowledge that I am responsible for the payment of services rendered, including any co-pays, deductibles, and out-of-pocket costs that may not be covered by insurance.
By signing this consent form, I affirm that I understand the information above, and I voluntarily consent to the treatment provided at Savage Family Medical Center.
Make sure to review the document carefully and ask questions if anything is unclear. If you are a minor or unable to sign on your own behalf, a guardian or legal representative will need to sign in your place.
If you are physically present at Savage Family Medical Center, you may need to sign this form in person or digitally (if they use electronic records). Always ensure that the consent is fully informed and that you understand your rights.
