Neurology Treatment Agreement and Informed Consent

Patient Information

Name: _________________________ Date of Birth: _________________ Medical Record #: ________________ Date: _________________________

Agreement Terms

1. Treatment Consent

I, the undersigned patient, consent to neurological evaluation and treatment by Dr. _________________ and associated healthcare providers. I understand that:

• Neurological examination may include physical tests, imaging studies, and diagnostic procedures
• Treatment recommendations will be based on my specific condition and needs
• No guarantees have been made regarding treatment outcomes

2. Patient Responsibilities

I agree to:

• Provide accurate and complete medical history
• Follow the prescribed treatment plan
• Attend scheduled appointments or provide 24-hour notice for cancellations
• Report any new symptoms or medication side effects promptly
• Inform the office of any changes in insurance or contact information

3. Medication Management

• I will take medications only as prescribed
• I understand that certain neurological medications require regular monitoring
• I will not seek similar medications from other providers without notification
• I agree to random drug screening if prescribed controlled substances

4. Communication and Follow-up

• Emergency contact: _______________________
• Preferred pharmacy: ______________________
• I understand that after-hours calls should be limited to urgent medical issues
• I agree to scheduled follow-up appointments as recommended

Signatures

Patient Signature: _________________________ Date: ____________

Provider Signature: ________________________ Date: ____________

Witness: _________________________________ Date: ____________