Medical Consent Form
Patient Information
Name
Age
Date of Birth
-
Month
-
Day
Year
Gender
Please Select
Male
Female
Email
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian or Emergency Contact Details
Contact Person Name
Primary Phone Number
Format: (000) 000-0000.
Secondary Phone Number
Format: (000) 000-0000.
Medical Data
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 PriorityYou Health Center to perform the treatment or necessary procedure to me/ or to my (for Parent/Guardian) dependent.
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 authorize blood transfusion for emergency purposes.
I understand the risk and complications if I do not follow the instructions given to me after the procedure which involves post-treatment and follow-ups.
I understand that I am not allowed to eat or drink 4-6 hours before the procedure.
I acknowledge that all information I provided int his form is true and accurate.
I acknowledge that I was offered access to the Notice of Privacy Practices and understand I may request a paper copy at any time.
YES
Patient/Parent/Guardian Signature
Date Signed
-
Month
-
Day
Year
Submit
Submit
Should be Empty: