Online Medical Consent Form
Patient Information
Name
Age
Date of Birth
-
Month
-
Day
Year
Gender
Please Select
Male
Female
Email
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Health Insurance Name
Insurance Policy ID
Parent/Guardian or Emergency Contact Details
Contact Person Name
Primary Phone Number
Secondary Phone Number
Medical Data
Blood Type
Please Select
A
B
AB
O
Are you wearing glasses or contact lenses?
Yes
No
Are you vaccinated? If yes, please list the vaccines you have received.
Do you have any known allergies? If yes, then please specify below.
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
What is your current medical condition? Do you have any communicable disease, cardiovascular problems, diabetes, asthma etc.?
Acknowledgment, Authorization and Waiver
I authorize Dr. Wolfe with Modern Foot and Ankle - A Division of Modern Medical Group to perform the treatment or necessary procedure listed below:
I confirm that the doctors explained the procedure thoroughly to me and how it will help me with my current condition.
I authorize the use of anesthesia and understands the side effects I can experience from it.
I understand there are post-procedure instructions which I will need to follow for recovery. I understand the risk and complications resulting in adverse events if I do not follow the instructions given to me after the procedure which involves post-treatment care and follow-ups appointments.
I acknowledge that all information I provided in this form is true and accurate.
Right to Withdraw: I understand that I have the right to withdraw my consent and refuse the procedure at any time before it is performed, without affecting my future care.
Consent Statement: I have read and understood the information provided above. I have had the opportunity to ask questions, and my questions have been answered to my satisfaction. I understand the nature, purpose, risks, and potential complications of the procedure, and I voluntarily agree to proceed with the procedure.
Patient/Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Name
First Name
Last Name
Submit
Submit
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