Consent For Care And Treatment Form

ADVERTISEMENT

DOB:
Chart Number:
Name:
E-mail:
Spouse/Partner Name:
Sex: OM OF Marital Status:
Single
Married
Widowed
Divorced
SS#:
E
-
mail
newsletters,
reminders,
statements, etc.
Address:
City:
State:
Zip:
Home #:
Cell #:
Other #:
Employer:
Phone:
Employer Address:
City:
State:
Zip:
CONSENT FOR CARE AND TREATMENT
I, the undersigned, having legal authority to do so, do hereby agree and give consent for Hal Bozof, DPM to furnish
medical care and treatment as considered necessary and proper in diagnosing or treating my/his/her medical condition.
HIPAA
I, the undersigned, have been made aware of my rights as a patient under the "Health Information Portability and
Accountability Act" as posted in the office. I further understand that I may request a printed copy of these rights at any
time.
MISSED APPOINTMENTS
Unfortunately we are experiencing many missed appointments. This makes it incredibly difficult to schedule prompt and
convenient appointment times for both existing and new patients, not to mention working in those who have an
immediate need to be seen. To relieve this problem in a way that is fair to everyone, we will begin charging $25 for a
missed appointment fee for patients who must cancel and do not give us a 24-hour notice. As a courtesy, please call
our office 24 hours ahead of your appointment time to let us know you need to cancel. You will avoid the
$25
missed
appointment fee, and we will gladly reschedule your appointment for a time more convenient for you.
I have read and understand the statement noted above.
How did you find out about our practice?
Physician
Internet 1:1 Telephone book
Family member 1:1 Friend
l=1 Other:
What is the reason for your visit today?
How long has this bothered you? I 2 3 4 5 6
7
days 121 weeks
months
years
What treatments have you tried & have they been effective?
On a scale of I - I 0 (I being no pain and I 0 being the worst) what is your level of pain?
/10
The pain quality is: Churning
constant
dull
sharp
shooting
throbbing
tingling Other:
Practice:
Today's Date:
PLEASE READ
AND SIGN
The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for
notifying the physician and/or medical staff of any and all updates to the information listed above.
Patient Signature:
Date:
Rev
12/29/2011

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go
Page of 4