Consent for Treatment Medical Form

General Surgeon

Consent for Treatment Purpose: As a patient, you have the right to be informed about your condition and the recommended medical or diagnostic procedure or drug therapy. This disclosure is not intended to alarm or frighten you, but rather to make you better informed is that you may give or withhold your consent to proposed treatments, including medications and procedures. By signing below, I voluntarily agree to the terms of this Consent for Treatment Form. Consent for Treatment: I voluntarily consent to treatment and evaluation as Dr. Shey Ditto, as my physician, shall deem necessary or advisable, to treat my condition. I hereby authorize Dr. Ditto and his staff to perform other additional or extended services in emergency situations if it may be necessary or advisable in order to preserve my life or health. I understand that it is my responsibility to actively participate in my care in order to maximize improvement in my condition. I understand that I may undergo extensive diagnostic tests and examinations during my treatment with Dr. Ditto. If I am unable or unwilling to undergo such testing, my treatment plan may be revised and my condition outcome may be affected. I understand that I have the right to refuse consent to any proposed procedure or treatment at any time prior to its performance I hereby consent to treatment. During the course of treatment, I may be required to make frequent follow-up visits to review diagnostic test results. I will be required to personally attend office visits for appropriate care and treatment. I agree to keep Dr. Ditto apprised of any changes in my medical condition. I understand certain diagnostic tests, treatments, and drug therapies can be dangerous under certain medical conditions or medication use. Pregnancy is one such medical consideration and females must be certain to acknowledge this condition prior to diagnostic imaging and initiation of any medication therapy. Female patients who become pregnant or believe they may be pregnant during the course of their treatment with Dr. Ditto will notify Dr. Ditto. Furthermore, I understand that medicine and surgery is not an exact science and I acknowledge that no promise, warranty or guarantee has or will be made to me as a result of any diagnostics, medication therapy, treatment, or course, including any cure of my condition. Signature_____________________________________________________________

There are 53 copies in use.
Published: Oct. 5, 2018, 3:05 p.m.
Doctor: Dr. History Physical
Rating: +16   /