Orthopedic Care Agreement and Informed Consent

Patient Information

Name: _________________________
Date of Birth: __________________
Medical Record #: _______________

Agreement Terms

1. Treatment Consent

I hereby authorize Dr. _________________ and associated healthcare providers to perform orthopedic evaluation, treatment procedures, and surgery if deemed necessary. I understand that:

• No guarantees have been made regarding treatment outcomes
• Additional procedures may be necessary during surgery
• Complications, though rare, may occur during or after treatment

2. Patient Responsibilities

I agree to:

• Provide accurate medical history and information
• Follow prescribed treatment plans and rehabilitation protocols
• Attend scheduled appointments or provide 24-hour notice for cancellations
• Report any complications or concerns promptly
• Complete prescribed physical therapy as directed

3. Medication Management

• I will use prescribed medications only as directed
• I will inform the practice of all current medications
• I understand that certain pain medications may require special agreements

4. Financial Responsibility

I acknowledge:

• Responsibility for applicable co-pays, deductibles, and non-covered services
• That insurance verification is not a guarantee of payment
• That I will be responsible for any collection fees if payment is defaulted

5. Image and Device Consent

I consent to:

• Radiological imaging as necessary for diagnosis and treatment
• Photographic documentation of condition and treatment
• The use of surgical implants if medically indicated

Signatures

Patient/Guardian: _________________ Date: _______

Provider: ________________________ Date: _______

Witness: _________________________ Date: _______