Cardiology Treatment Agreement and Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record #: ______________ Date: _____________________

Agreement Terms

1. Consent for Treatment

I, the undersigned patient, consent to receive cardiovascular care, which may include:

• Diagnostic testing and procedures
• Cardiovascular interventions
• Medication management
• Emergency cardiac care when necessary

2. Financial Responsibility

I understand that:

• I am responsible for all charges not covered by insurance
• Prior authorization may be required for certain procedures
• Copayments are due at the time of service

3. Medication Management

I agree to:

• Take medications as prescribed
• Inform the practice of any medication changes
• Report any adverse effects promptly
• Not share prescribed medications with others

4. Follow-up Care

I will:

• Attend scheduled appointments
• Follow recommended lifestyle modifications
• Complete prescribed cardiac rehabilitation programs
• Maintain regular communication with the practice

5. Emergency Procedures

I understand that in case of cardiac emergency:

• Immediate interventions may be necessary
• Transfer to appropriate facilities may be required
• Additional consent forms may be needed for specific procedures

Signatures

Patient Signature: _________________ Date: _______________

Provider Signature: ________________ Date: _______________

Witness Signature: _________________ Date: _______________

Practice Information

[Practice Name] [Address] [Contact Information]