List ALL indivduals who have parental rights and/or have legal guardianship of the minor.
Even if you answered “NO” to the above question, please indicate your current or planned method of contraception if you were to become sexually active:
Please list ALL medications you take, including prescription & over-the-counter medications, recent vaccinations (within the past 5 years), and vitamin supplements. Please make sure t o include medications you take only as-needed (for example, taking Advil f or occasional headache). *If you are taking medications and can’t remember the name, include these too and tell us what you do know and call us ASAP with the details.
I, [Patient Name]* , hereby certify that the health information I provide to the staff of Medical Research Group of Central Florida and any party affiliated with Medical Research Group of Central Florida is true, complete and accurate.I understand that the staff physicians will consider the information I have provided to make medical decisions and I understand that giving false, misleading or incomplete information could cause serious adverse health events.With my signature below, I hereby authorize the providers of this facility to conduct a consultation for the purposes of determining appropriateness for participation in a current or future clinical trial. I understand that, by signing this form, I am in no way obligated to start or continue participation in any current or future clinical trial nor am I promised eligibility to participate. I also understand that staff providers may recommend treatment according to my medical status and/or mental health and I will take these recommendations into consideration and follow-up with my current mental health provider, primary care physician and/or recommended community resources. Consultation assessments are at the discretion of the provider and may include but are not limited to:• Requests for medical records from past and/or current treating providers• Collection of demographics and medical history, including medical records• Obtaining measurements and vital signs• Pregnancy testing• Lab testing including urine drug screen• Referral for evaluation by another physician/specialist