Consent to Care and Treatment Form

Policy Statement

In order for us to proceed with the care and treatment,  we would like seek first the consent of our patients in order to secure legally our patient's rights.

Scope

This consent covers the healthcare and welfare of our patients. It is our responsibility to ensure that the necessary treatment or procedure is performed. But we cannot do this on our own and without the knowledge of the patient. We respect that the right of the person with his or her own body is a fundamental right and thus, we need to ensure that the person is giving his or her express acknowledgment and consent to the treatments and that the said patient is aware of the risks or consequences, if there is any, with regard to our actions.

Purpose

We would like to let you know about the care and treatment that you will receive from us and obtain your consent to allow us to provide you the care you will need. For patients below 18 years of age and those who are not capable of making informed decisions on their own under the law, parents or guardians may sign this form and make informed choices on the patient's behalf.

Patient's Withdrawal

The patient understands that he/she can decline and withdraw his/her consent and participation at any time, provided that such withdrawal shall be made in writing and signed by the withdrawing party.

Emergency Cases

There might be instances where the exigencies in situations, may prompt the Clinic to make urgent decisions on behalf of the patient. In these instances, the acceptance of this consent shall give the Clinic authority to make such decisions under such circumstances.

Billing and Collection

For any treatment and care conducted by the Clinic, the clinic is being given permission to share information with the patient's insurance company for the expenses incurred, as well as any third party that may be involved for the billing.

The patient, parent, or guardian may notify the Clinic beforehand should the former prefer not to disclose such information and may opt to make other modes of payment other than insurance.

Injuries or Disabilities

The Patient understands that certain information may be disclosed to the employer for work-related injuries or illnesses for evaluation and to help the employer address safety concerns in the workplace relative to the incident.

Authentication of Identification

The Clinic may require the patient, parent, or guardian to provide identification in connection with the treatment and care to be requested. This helps the Clinic
ensure the Clinic that the person treated is an authorized person under the insurance policy.

If the patient, parent, or guardian is not able to provide the necessary identification, the former may have an option to make payment in cash in order to be given treatment and care.

By signing this form, I acknowledge and understand that there may be other treatments methods under which I am undergoing in this treatment and care process. I have read and fully understand all of the above information. I have had the opportunity to ask questions and which all were answered to me and to my satisfaction. I am signing this form with full consent and without any form of misrepresentation, coercion, or duress.