I. CONSENT FOR MEDICAL TREATMENT
I hereby consent to the performance of such medical treatment, as deemed necessary or advisable by my provider and/or their associates. I hereby consent to the performance of all technical procedures and tests as directed by my provider. I am aware that the practice of Medicine is not an exact science and I acknowledge that no guarantees have been made to me as a result of treatments or examination.
II. CONSENT FOR TRANSFERS OF BIOLOGICAL SPECIMENS
During the course of your treatment, urine may be obtained for diagnostic purposes. Any such biological materials will be transferred via a third party company to an approved facility for either diagnostic evaluation, testing or destruction.
III. CONSENT TO SHARE SENSITIVE HEALTH INFORMATION WITHIN YOUR MEDICAL RECORD
I am aware that sensitive health information (SHI) such as drug/alcohol dependency, mental illness, psychological disorders, domestic violence and HIV/AIDS status discussed and disclosed to my provider will be included as part of my patient documents. This health information may be available to other healthcare providers for treatment and/or healthcare. Additionally, I agree that my provider and/or their associates may access my prescription history from external sources to better manage my medical needs and provide a higher level of care.
By signing below, as patient/legal representative or guarantor, I hereby agree to all of the above