The following statement of your rights and responsibilities is presented as the policy of The Children's Clinic of Conway & Greenbrier but does not presume to be a complete representation of all mutual rights and responsibilities.

• To impartial access to the medical resources of The Children's Clinic of Conway & Greenbrier without regard to race, color, national origin, age, sex, handicapping or disabling condition, spiritual or ethical beliefs or source of payment.
• To receive considerate, respectful care, which always recognizes your child's personal dignity and under all circumstances.
• To participate in decisions involving your child's care. Except in emergency, your child shall not be subjected to any procedure without your voluntary, competent, and understanding consent or the consent of your legally authorized representative.
• To refuse treatment to the extent permitted by law and to be informed of the consequences of that refusal.
• To instructional and educational information about your child's medical treatment in a language and terms that you understand.
• To the confidential treatment of and personal access to your child's medical record.
• To know who is responsible for providing your child's direct care and to receive information conceming your child's continuing health care needs and alternative for meeting those needs.

• To give your provider and The Children's Clinic of Conway & Greenbrier staff complete and accurate information about your child's condition and care.
• To follow instructions of your provider and the staff of The Children's Clinic of Conway & Greenbrier and to keep appointments relative to your child's care.
• To make it known whether you clearly understand planned actions and treatment and what is expected of you.
• To report unexpected changes in your child's condition to your provider or staff of The Children's Clinic of Conway & Greenbrier.
• To accept the financial obligations associated with your child's care.
• To advise your provider or any office staff members of any dissatisfaction you may have regarding your child's care.
• To be considerate of other patients and of staff members who are caring for your child.
• To bring a current copy of any advance directives at the time of the first visit to be placed in your medical record.

*The signature covers the above authorizations and consents for the patient listed below.