Patient Information
Name: ______________________________
Date of Birth: _______________________
Medical Record Number: _______________
Agreement Terms
1. Appointment Compliance
- I agree to attend all scheduled appointments or provide at least 24 hours notice for cancellations
- I understand that missing three appointments without notice may result in discharge from the practice
- I will arrive on time for appointments with necessary documentation and test results
2. Treatment Protocol
- I will follow the prescribed treatment plan, including medication schedules and lifestyle modifications
- I will regularly monitor my blood glucose/hormone levels as directed
- I agree to complete all recommended laboratory tests and imaging studies
- I will maintain an accurate log of home measurements when required
3. Medication Management
- I will take medications as prescribed and not alter dosages without consultation
- I will request prescription refills during scheduled appointments or with 72 hours notice
- I understand that certain hormone medications require careful monitoring and regular follow-up
4. Communication Guidelines
- I will promptly report any significant changes in my condition
- I understand that emergency situations require immediate emergency room evaluation
- I agree to respond to practice communications regarding test results or treatment modifications
5. Financial Responsibilities
- I understand my insurance coverage and financial obligations
- I agree to pay applicable copays and deductibles at the time of service
- I will promptly notify the practice of any insurance changes
Acknowledgment
I have read and understand this agreement. I acknowledge that failure to comply may result in discontinuation of care.
Patient Signature: _____________________ Date: __________
Provider Signature: ____________________ Date: __________
Practice Information
Clinic Name: _________________________
Provider Name: _______________________
Contact Information: __________________