Authorization for Medical Treatment at Urgent Care

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

Consent for Treatment

I, the undersigned patient, parent, or legal guardian, consent to medical treatment, diagnostic procedures, and/or minor surgical treatment by this urgent care facility's medical providers and staff. I acknowledge that:

• No guarantees have been made regarding the outcome of treatment
• I have the right to refuse any procedure or treatment
• I have the right to discuss all medical treatments with my provider

Financial Agreement

1. I understand that I am financially responsible for all charges, whether covered by my insurance or not
2. I authorize my insurance benefits to be paid directly to [Urgent Care Name]
3. I authorize the release of medical information necessary to process insurance claims

Notice of Privacy Practices

I acknowledge that I have received or been offered a copy of this facility's Notice of Privacy Practices.

Emergency Contact

Name: _________________________ Relationship: _____________ Phone: ________________________

Signatures

Patient/Guardian Signature: _________________ Date: _________

Witness Signature: _________________________ Date: _________

This authorization is valid for one year from the date of signature unless revoked in writing.