This consent form provides general consent for healthcare services, including diagnostic, therapeutic, and preventive medical care. By signing this form, you acknowledge your understanding of the healthcare services that may be provided and your consent to receive those services.
1. Consent to General Healthcare Services: I voluntarily consent to receive healthcare services, including but not limited to: - Routine examinations and diagnostic evaluations - Laboratory tests, imaging, and other diagnostic procedures I understand that my healthcare provider will explain the purpose and nature of any proposed procedures, treatments, or services. I am encouraged to ask questions and have them answered to my satisfaction before any treatment is rendered.
2. Acknowledgment of Risks and Benefits: I understand that healthcare services and treatments may involve risks and complications, including, but not limited to: - Adverse reactions to medications or treatments - Unanticipated outcomes, including worsening of symptoms or conditions I also understand that healthcare services may have significant benefits, including diagnosing and treating medical conditions, alleviating symptoms, preventing illness, and improving overall health.
3. Refusal of Treatment: I understand that I have the right to refuse any treatment or procedure recommended by my healthcare provider. If I choose to refuse a recommended treatment, I understand that I should discuss the potential risks and consequences of my decision with my provider. I also understand that I may revoke my consent to treatment at any time.
4. Confidentiality and Privacy: I understand that my personal health information will be kept confidential and protected under the Health Insurance Portability and Accountability Act (HIPAA). My healthcare provider may share my health information with other healthcare providers or entities involved in my care as necessary in compliance with applicable laws and regulations.
5. Financial Responsibility: I understand that I am financially responsible for any services provided, including the cost of consultation and medication management fees if applicable. I acknowledge that a consultation fee is required at the time of booking. Should I choose to move forward with proposed medical services, I understand that this fee will apply to my visit total.
6. Acknowledgment of Alternatives: I understand that there may be alternative treatment options available, and that I am encouraged to discuss these alternatives with my healthcare provider. I may also seek a second opinion regarding my care if I choose to do so.
7. Patient’s Rights and Responsibilities: I acknowledge that I have been provided with information regarding my rights as a patient, including the right to make decisions about my care, the right to respectful and confidential treatment, and the right to be informed of my diagnosis and treatment options. I also understand my responsibility to provide accurate and complete information about my health, follow treatment plans, and communicate with my healthcare provider.
8. Acknowledgment of Understanding: I have read and fully understand the information in this consent form. I have had the opportunity to ask questions, and all of my questions have been answered to my satisfaction. I understand that this general consent applies to all healthcare services provided by my healthcare provider and that I may be asked to provide additional consents for specific treatments or procedures.
9. Consent for telemedicine services: I understand that participation in telemedicine services is voluntary and that I have the option to seek in-person care instead of telemedicine. I acknowledge that I have the right to withdraw my consent for telemedicine services at any time without affecting my future care or treatment.
10. Consent for Treatment: I hereby give my consent to receive healthcare services as recommended by my healthcare provider. I understand that I may withdraw my consent at any time and that my withdrawal will not affect the care I receive for services already provided.
Patient’s Name Printed:
Patient’s Name Signed:
Date:
Date Of Birth:
Provider’s Name Printed: Dr. Hanan Hussein and her team associates
