Informed Consent Routine and Preventive Medical Care

INFORMED CONSENT ROUTINE AND PREVENTIVE MEDICAL CARE
I authorize Triangle, Inc. to arrange for my routine and preventive medical treatment during the period from:date* todate* . This care will be provided by the physicians listed on my health record, except in emergency situations. This treatment includes an annual physical exam, routine dental care, an annual eye exam and an annual ear exam. The purpose of this treatment is to maintain an optimum level of health.
Only those procedures that are commonly accepted as part of a routine physical exam or routine treatment of a minor illness or injury will be used. I understand that this treatment may involve a slight degree of temporary pain or discomfort, but that these effects will not be long lasting or significant.

I give consent voluntarily, without threat of punishment or promise of a special reward. I have been given an opportunity to fully discuss this consent and to have my questions answered. I have also been offered a copy of this form. I understand that I may request a full explanation of each procedure at the time of treatment and that I have the right to withdraw consent at any time from one or all of the procedures without threat of punishment. This consent expires after one year.
Individual's Signature*

Clear
Date*

MonthDayYear
Date
Guardian's Signature*

Clear
Date*

MonthDayYear
Date
Signature and Position of Person Obtaining Consent

Clear
Date

MonthDayYear
Date

Preview PDF, Save, and Submit
Please enter an email address here if you'd like to receive confirmation that this form was submitted successfully and a copy of this form.
example@example.com
Should be Empty: