Consent for Treatment & Conditions of Service

IMPORTANT: SIGN THIS FORM ONLY AFTER READING AND UNDERSTANDING ITS CONTENTS.

In consideration of services provided by PREventClinic, Inc, the Patient (or undersigned representative acting on behalf of the Patient) agrees and consents to the following:

1. Consent to Routine Medical Treatment/Services

Patient consents to the rendering of Medical Treatment/Services as considered necessary and appropriate by the attending physician or other practitioner, a member of the PREventClinic medical staff who has requested care and treatment of Patient, and others with staff privileges at PREventClinic. Medical Treatment/Services may be performed by “Healthcare Professionals” (physicians, nurses, technologists, technicians, physician assistants or other healthcare professionals). Patient authorizes the attending or other practitioner, the medical staff of PREventClinic to provide Medical Treatment/Services ordered or requested by attending or other practitioner and those acting in his or her place. The consent to receive “Medical Treatment/Services” includes, but is not limited to: examinations (EKGs, echocardiograms or otherwise); laboratory procedures; medications; infusions; drugs; supplies; medical treatments; recording/filming for internal purposes (i.e., identification, diagnosis, treatment, performance improvement, education, safety, security) and other services which patient may receive. In the event PREventClinic determines that Patient should provide blood specimens for testing purposes in the interest of the safety of those with whom Patient may come in contact; Patient consents to the withdrawing and testing of Patient’s blood and to the release of test information where this is deemed appropriate for the safety of others.

2. Legal Relationship between Hospital and Physician

Some of the healthcare professionals performing services at PREventClinic offices may be independent contractors and are not PREventClinic agents or employees. Independent contractors are responsible for their own actions and PREventClinic shall not be liable for the acts or omissions of any such independent contractors.

3. Explanation of Risk and Treatment Alternatives

Patient acknowledges that the practice of medicine is not an exact science and that NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO THE PATIENT concerning the outcome and/or result of any Medical Treatment/Services. While routinely performed without incident, there may be material risks associated with each of these Medical Treatment/Services. Patient understands that it is not possible to list every risk for every Medical Treatment/Services and that this form only attempts to identify the most common material risks and the alternatives (if any) associated with the Medical Treatment/Services. Patient also understands that various Healthcare Professionals may have differing opinions as to what constitutes material risks and alternative Medical Treatment/Services. By signing this form:
Patient consents to Healthcare Professionals performing Medical Treatment/Services as they may deem reasonably necessary or desirable in the exercise of their professional judgment, including those Medical Treatment/Services that may be unforeseen or not known to be needed at the time this consent is obtained; and Patient acknowledges that Patient has been informed in general terms of the nature and purpose of the Medical Treatment/Services; the material risks of the Medical Treatment/Services and practical alternatives to the Medical Treatment/Services.

The Medical Treatment/Services may include, but are not limited to the following:

• a).  Needle Sticks, such as shots, injections, intravenous lines or intravenous injections (lVs). The material risks associated with these types of Procedures include, but are not limited to, nerve damage, infection, infiltration (which is fluid leakage into surrounding tissue), disfiguring scar, loss of limb function, paralysis or partial paralysis or death. Alternatives to Needle Sticks (if available) include oral, rectal, nasal or topical medications (each of which may be less effective).
• b).  Physical Tests, Assessments and Treatments such as vital signs, internal body examinations, wound cleansing, wound dressing, range of motion checks and other similar procedures. The material risks associated with these types of Procedures include, but are not limited to, allergic reactions, infection, severe loss of blood, muscular-skeletal or internal injuries, nerve damage, loss of limb function, paralysis or partial paralysis, disfiguring scar, worsening of the condition and death. Apart from using modified Procedures, no practical alternatives exist.
• c).  Administration of Medications via appropriate route whether orally, rectally, topically or through Patient’s eyes, ears or nostrils, etc. The material risks associated with these types of Procedures include, but are not limited to, perforation, puncture, infection, allergic reaction, brain damage or death. Apart from varying the method of administration, no practical alternatives exist.
• d).  Drawing Blood or Bodily Fluids such as that done for laboratory testing and analysis. The material risks associated with this type of Procedure include, but are not limited to, paralysis or partial paralysis, nerve damage, infection, bleeding and loss of limb function. Apart from long-term observation, no practical alternatives exist.
• e).  Insertion of Internal Tubes such as bladder catheterizations, nasogastric tubes, rectal tubes, drainage tubes, enemas, etc. The material risks associated with these types of Procedures include, but are not limited to, internal injuries, bleeding, infection, allergic reaction, loss of bladder control and/or difficulty urinating after catheter removal. Apart from external collection devices, no practical alternatives exist.
• f).  Radiological Studies such as X-rays, CT scans or MRI scans. The material risks associated with these types of Procedures include, but are not limited to, radiation exposure.

If Patient has any questions or concerns regarding these Medical Treatment/Services, Patient will ask Patient’s attending provider to provide Patient with additional information. Patient also understands that Patient’s attending or other provider may ask Patient to sign additional informed consent documents concerning these or other Medical Treatment/Services.

4. Healthcare Practitioners in Training

Patient recognizes that among those who may attend Patient at PREventClinic are medical, nursing and other health care personnel who are in training and who, unless specifically requested otherwise, may be present and participate in patient care activities as part of their medical education. There also may be present from time to time a medical product or medical device representative. Consent is hereby given for the presence and participation of such persons as deemed appropriate by the attending physician.

5. Remaining in Patient Care Area and Closed Circuit Monitoring/Videotaping/Photography

Patient acknowledges and understands that, Patient is advised to remain in the patient care area at all times to optimize Patient’s medical care and safety. If Patient chooses to leave the area for reasons that are not treatment related, Patient assumes any and all liability for any incident, accident, misadventure or harm, including deterioration of Patient’s condition, which Patient may suffer. Patient agrees to hold PREventClinic, all Healthcare Professionals, harmless for any injury or harm resulting from Patient’s decision to leave the patient care area and Patient accepts any and all responsibility for such actions. Patient also understands that closed circuit monitoring, videotaping and photography patient care may be used for educational, clinical purposes and/or safety related purposes.

6. Authorization to Release Information

PREventClinic is authorized to release information contained in the patient record. The information authorized to be released shall include, but is not limited to, infectious or contagious disease information, including HIV or AIDS-related evaluations, diagnosis or treatment; information about drug or alcohol abuse or treatment of same and/or psychiatric or psychological information. Patient waives any privilege pertaining to such confidential information. PREventClinic, its agents and employees are hereby released from any and all liabilities, responsibilities, damages, claims and expenses arising from the release of information as authorized above. Reasons for releasing a Patient’s record include, but are not limited to, insurance company(s), their agents or other third party payor and/or government or social service agencies which may or will pay for any part of the medical/hospital expenses incurred or authorized by representatives of PREventClinic, as mandated by law, or to alternate care providers, including community agencies and services, as ordered by Patient’s physician or as requested by Patient or Patient’s family for post-hospital care. PATIENT ACKNOWLEDGES AND AGREES THAT PATIENT’S RECORDS WILL BE AVAILABLE TO ALL PREventClinic AFFILIATED ENTITIES AND PROVIDERS, AND TO NON-PREventClinic AFFILIATED REFERRING PROVIDERS IN COMPLIANCE WITH THE PROVISIONS OF MEANINGFUL USE. Patient also agrees, in order for PREventClinic to service accounts or to collect liabilities owed, to receive contact by telephone at any telephone number associated with their record, including wireless telephone numbers, which could result in charges to Patient. PREventClinic or its agents may also contact Patient by sending text messages or emails, using any email address Patient provides. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

7. Patient Survey

Patient authorizes PREventClinic and/or its authorized representative to contact Patient after the date of service for the purpose of conducting patient satisfaction surveys and other studies.

8. Patient Rights and Personal Valuables

Patient acknowledges that Patient has received a copy of Patient Rights and has verified the information utilized during this registration and confirms its accuracy. PREventClinic shall not be liable for the loss or damage of any personal belongings, including but not limited to money, cell phones, laptops, electronic devices, jewelry, hearing aids, computers or dentures, unless properly secured and placed within the hospital safe.

9. Consent Timeframe and Applicability

The above consents are applicable to all inpatient and outpatient hospital-based services, as well as all ambulatory and physician office based services. With respect to inpatient hospital based services, including infants delivered and newborn care at any PREventClinic affiliate, the consents shall be valid for a period of 30 days from the date of signature below or for the period of time Patient is confined in the hospital for a particular purpose, whichever is greater. For outpatient-based hospital services, the above consents are valid for a period of 30 days from the date of signature below; provided, however, that if outpatient hospital-based services are provided through serial visits, the above consents will be valid for a term of one (1) year from the date of signature below. For all ambulatory or physician office based services, the above consents are valid for a period of one (1) year from the date of signature below.

Validity of Form

Patient acknowledges that a copy, or an electronic version of this document may be used in place of and is as valid as the original.

Patient understands that the Healthcare Professionals participating in the Patient’s care will rely on Patient’s documented medical history, as well as other information obtained from Patient, Patient’s family or others having knowledge about Patient, in determining whether to perform or recommend the Procedures; therefore, Patient agrees to provide accurate and complete information about Patient’s medical history and conditions.

Patient confirms that Patient has read and understood and accepted the terms of this document and the undersigned is the Patient, the Patient’s legal representative or is duly authorized by the Patient as the Patient’s general agent to execute the above and accept its terms.

 

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Patient (or Patient Representative) Signature                    Patient Name (PRINT)                                     Date Time

 

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Relationship to Patient                                                                 Reason Patient is unable to sign                      Date Time

 

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PREventClinic, Inc Representative Name (Signature)    PREventClinic, Inc Representative Name (PRINT)            Date Time