Urgent Care Patient Informed Consent Form

Patient Information

Name: ___________________________ Date of Birth: //___ Address: _________________________ Phone: ________________

Consent for Medical Treatment

I, the undersigned patient or legal guardian, hereby authorize [CLINIC NAME] and its medical providers to perform medical treatment, diagnostic procedures, and administer medications as deemed necessary for my care.

Understanding of Care

• I understand that medicine is not an exact science and no guarantees have been made regarding treatment outcomes
• I acknowledge that I have the right to ask questions about my condition, treatments, and alternatives
• I understand that this urgent care facility is not an emergency room and cannot treat life-threatening conditions

Financial Responsibility

• I agree to be financially responsible for all charges incurred during my visit
• I authorize my insurance benefits to be paid directly to [CLINIC NAME]
• I understand that I am responsible for any balance not covered by insurance

Privacy Practices

I acknowledge receipt of the Notice of Privacy Practices and consent to the use and disclosure of my health information for treatment, payment, and healthcare operations.

Right to Refuse Treatment

I understand that I have the right to refuse any medical treatment or procedures at any time.

Signatures

Patient/Guardian Signature: ___________________ Date: //___

Witness Signature: __________________________ Date: //___

Provider Attestation

I have explained the nature of the treatment, expected benefits, material risks, and alternative options to the patient/guardian.

Provider Signature: _________________________ Date: //___