Urgent Care Patient Treatment Agreement

Patient Information

Name: _________________________ Date of Birth: _________________ Address: _______________________ Phone: _______________________

1. Consent for Treatment

I hereby consent to medical evaluation, testing, and treatment provided by the staff at [CLINIC NAME] Urgent Care Center. I understand that:

• Medical providers will explain recommended treatments
• I have the right to refuse any procedure or treatment
• No guarantees are made regarding the outcome of treatment

2. Financial Agreement

I understand that:

• Payment is expected at the time of service
• I am responsible for any charges not covered by insurance
• Co-payments and deductibles are due at time of service
• There is a $25 fee for returned checks

3. Insurance Authorization

I authorize:

• Direct payment of medical benefits to [CLINIC NAME]
• Release of medical information necessary to process claims
• [CLINIC NAME] to act as my authorized representative

4. Communication Consent

I consent to receive:

• Automated appointment reminders
• Follow-up care instructions
• Lab and diagnostic test results Preferred contact method: □ Phone □ Email □ Text

5. Notice of Privacy Practices

I acknowledge receipt of the Notice of Privacy Practices and understand my health information may be used for:

• Treatment
• Payment
• Healthcare operations

Signature

Patient/Guardian Signature: _________________ Date: __________ Witness Signature: ________________________ Date: __________

This agreement remains in effect until revoked in writing.