Endocrinology Treatment Agreement and Consent Form

Patient Information

Name: _________________________ Date of Birth: _____________ Medical Record Number: __________ Date: _____________________

Agreement Terms

1. Treatment Compliance

• I agree to take all prescribed medications as directed by my endocrinologist
• I will maintain all scheduled appointments or provide 24-hour notice for cancellations
• I will complete all ordered laboratory tests as scheduled
• I understand that missing appointments may result in interruption of medication prescriptions

2. Monitoring Requirements

• I agree to regular monitoring of my endocrine condition through:
  • Blood tests
  • Physical examinations
  • Other diagnostic procedures as recommended
• I will maintain a log of relevant symptoms and measurements as instructed

3. Medication Management

• I will only obtain endocrine medications from this practice unless otherwise arranged
• I will inform my endocrinologist of all other medications, supplements, and treatments
• I understand that sudden discontinuation of endocrine medications can be dangerous

4. Emergency Protocols

• I have received instructions for managing endocrine emergencies
• I will carry appropriate emergency medications/supplies as prescribed
• I understand when to seek immediate medical attention

5. Communication

• I will promptly report any significant changes in my condition
• I will inform the practice of any changes in contact information or insurance
• I agree to respond to requests for information from the practice

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: _________________