Gastroenterology Authorization for Treatment and Consent Form

Patient Information

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

Authorization for Medical Treatment

I, the undersigned patient (or authorized representative), consent to medical care and treatment at [Practice Name] provided by the gastroenterology physicians, allied health professionals, and staff.

Scope of Consent

• Examination, diagnosis, and treatment
• Routine diagnostic procedures
• Endoscopic procedures as deemed necessary
• Administration of medications and treatments
• Collection of specimens

Understanding and Acknowledgment

1. I understand that:

   • The practice of medicine is not an exact science
   • No guarantees have been made regarding treatment outcomes
   • There may be risks associated with recommended procedures
   • Additional procedures may be necessary based on findings

2. I acknowledge that:

   • I have the right to ask questions about proposed treatments
   • I can refuse any procedure or treatment
   • I will inform my healthcare providers of any changes in my condition

Financial Responsibility

I understand that I am financially responsible for all charges regardless of insurance coverage.

Release of Information

I authorize the release of medical information necessary for treatment, payment, and healthcare operations.

Signature

Patient/Guardian Signature: _________________ Date: __________

Witness Signature: _________________________ Date: __________

Physician Signature: _______________________ Date: __________