CONSENT FORM FOR DIRECT PREVENTIVE CARE
I, [Patient Name], hereby consent to and authorize the provision of medical care and treatment by the healthcare professionals at Direct Preventive Care. This consent is given voluntarily and is valid for the duration of my care at this facility.
CONSENT FOR MEDICAL TREATMENT:
I understand that the medical practitioners at Direct Preventive Care may need to perform various diagnostic, therapeutic, and preventive medical procedures to assess and address my health condition. These procedures may include but are not limited to physical examinations, laboratory tests, medical imaging, medications, and minor surgical procedures.
DISCLOSURE OF MEDICAL INFORMATION:
I acknowledge that the healthcare providers may need to collect, use, and disclose my personal and medical information for the purpose of providing medical care, obtaining insurance coverage, and complying with legal and regulatory requirements. I understand that my health information will be treated in accordance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
INFORMED CONSENT:
The healthcare providers will explain the nature, purpose, risks, benefits, and alternatives of any proposed medical procedure or treatment to the best of their ability. I understand that I have the right to ask questions, seek clarification, and discuss any concerns before agreeing to any medical intervention. I have been provided with sufficient information to make an informed decision.
MINOR PROCEDURES AND TREATMENTS:
I understand that certain minor procedures or treatments may be performed during the course of my medical care. These may include, but are not limited to, wound care, IV Therapy, and other routine medical interventions. I consent to these procedures unless I specifically express my objection.
PHOTOGRAPHIC AND AUDIOVISUAL RECORDINGS:
I acknowledge that the medical practitioners may, for medical and educational purposes, take photographic or audiovisual recordings related to my treatment. I grant permission for the use of such recordings within the confines of the medical practice.
FINANCIAL RESPONSIBILITY:
I understand that I am responsible for any financial obligations related to the medical services provided. I acknowledge that I have been informed of the financial policies of Direct Preventive Care.
I have read and understood the information provided in this consent form. I am aware that I have the right to refuse any medical treatment or procedure and that my consent is voluntary.