Patient Consent for Treatment :
I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Forward Care Family Practice and its associated physicians, clinicians and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at Forward Care Family Practice.
I consent to the use and disclosure of my/the patient's protected health information for purposes of obtaining payment for services rendered to me/the patient, treatment and health care operations consistent with the Forward Care Family Practice Notice of Privacy Practices.
Iauthorize payment of medical benefits to Forward Care Family Practice physicians or their designee for services rendered.
I give permission to obtain all my medication/prescriptior history when using an electronic system to process prescriptions for my medical treatment.
I have received a copy of the Notice of Privacy Practice, Financial Policy Notice and the Release of Information.
I am granting permission to Forward Care Family Practice to leave phone messages regarding my child's medical health to the number(s) provided on the registration form.