Orthopedic Treatment and Consent Agreement

Patient Information

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

1. Consent for Treatment

I, the undersigned, consent to orthopedic evaluation and treatment by Dr. _________________ and their associates. I understand that this may include:

• Physical examinations
• Diagnostic imaging (X-rays, MRI, CT scans)
• Laboratory tests
• Injections and medications
• Physical therapy
• Surgical procedures (if deemed necessary)

2. Financial Responsibility

• I understand that I am responsible for all charges regardless of insurance coverage
• I agree to pay any co-payments, deductibles, or non-covered services
• I authorize my insurance benefits to be paid directly to [Practice Name]

3. Treatment Risks and Benefits

I acknowledge that:

• No guarantees have been made regarding treatment outcomes
• Potential risks and complications have been explained to me
• I have had the opportunity to ask questions about my treatment

4. Follow-up Care Agreement

I agree to:

• Follow the prescribed treatment plan
• Attend scheduled follow-up appointments
• Report any unexpected changes in my condition
• Comply with physical therapy and rehabilitation protocols

5. Photography Consent

I permit medical photographs to be taken for:

• Documentation of my condition
• Treatment planning
• Educational purposes (with separate consent)

Signatures

Patient/Guardian: ______________________ Date: __________

Witness: _____________________________ Date: __________

Physician: ___________________________ Date: __________