Patient Information
Name: ___________________________
Date of Birth: ____________________
Medical Record #: _________________
Agreement Terms
1. Appointment Policies
- I agree to arrive 15 minutes before scheduled appointments
- I will provide 24-hour notice for cancellations
- I understand that three missed appointments may result in discharge from the practice
- I accept that repeated late arrivals may require rescheduling
2. Medical Information
- I will provide complete and accurate medical history
- I will inform the practice of all current medications
- I will update the practice about care received from other providers
- I will promptly report any adverse reactions or complications
3. Treatment Compliance
- I agree to follow prescribed treatment plans
- I will complete recommended screening procedures
- I will adhere to prescribed medication schedules
- I understand the importance of lifestyle modifications as recommended
4. Communication
- I consent to receive communications via patient portal
- I will respond to practice inquiries within 48 hours
- I will keep contact information current
- I understand emergency situations require calling 911
5. Financial Responsibility
- I accept responsibility for applicable copays and deductibles
- I will maintain current insurance information
- I understand some procedures may require pre-authorization
- I agree to pay outstanding balances within 30 days
Signatures
Patient Signature: _________________ Date: _______
Provider Signature: ________________ Date: _______
Practice Information
[Practice Name]
[Address]
[Contact Information]
[Hours of Operation]