Urgent Care Patient-Provider Agreement and Consent for Treatment

Patient Information

Name: _________________________ Date of Birth: _____________ Address: _______________________ Phone: ___________________

1. Consent for Treatment

I hereby authorize the medical providers at [CLINIC NAME] to provide medical care, perform necessary tests, and administer treatments as deemed appropriate for my condition.

2. Financial Responsibility

• I understand that payment is due at the time of service
• I authorize direct payment of medical benefits to [CLINIC NAME]
• I accept responsibility for any charges not covered by my insurance

3. Communication Agreement

I authorize [CLINIC NAME] to:

• Contact me via phone, text, or email regarding my care
• Leave messages regarding appointments and test results
• Share my medical information with my designated emergency contacts

4. Notice of Privacy Practices

I acknowledge receipt of the Notice of Privacy Practices and understand how my medical information may be used.

5. After-Hours Care

• I understand this is not an emergency facility
• For emergencies, I will seek care at the nearest emergency department
• Follow-up care may be referred to my primary care physician

6. Prescription Policy

• I understand that prescriptions are provided at the provider's discretion
• Controlled substances may not be prescribed at this facility
• Prescription refills require an appointment

Patient Signature: _________________ Date: _______________

Provider Signature: ________________ Date: _______________

This agreement remains in effect until revoked in writing by the patient