Spark Electric

System Template Active Healthcare

General informed consent for medical treatment

Fields

Used

Submitted

Form Preview

Patient Information

Patient Name *

Date of Birth *

Consent for Treatment

I hereby consent to receive medical treatment from the healthcare provider. I understand that the practice of medicine is not an exact science and acknowledge that no guarantees have been made to me regarding the outcome of any treatment.

I have been informed of the nature and purpose of the proposed treatment, the risks and benefits involved, and any alternative treatments available. I have had the opportunity to ask questions and all of my questions have been answered to my satisfaction.

I understand and consent to the proposed treatment * Yes

I understand the potential risks and benefits * Yes

I have had the opportunity to ask questions * Yes

Financial Responsibility

I understand that I am financially responsible for all charges not covered by my insurance. I authorize direct payment to the healthcare provider for any services rendered.

I accept financial responsibility for services rendered * Yes

Signature

Patient/Guardian Signature *

Signature pad

Printed Name *

Relationship to Patient (if guardian)