CONSENT/ FOLLOW UP INFORMATION
For follow up, such as lab results, X-Ray reports, or billing matters, I prefer AHP to notify me by phone or email at:
____________________________
If AHP cannot reach me by phone, I authorize AHP to
leave a detailed message about the care of the patient.
I certify that the above information is true and I consent to any medical or surgical treatment rendered to the patient under the general or special instructions of the physician. I understand I may review in detail AHP’s Privacy Practices. I am aware of my right to request special privacy considerations.
Signature of: Mother FatherGrandparent Adult
Parent/Guardian X _____________ ____________________________