PATIENT AGREEMENT Sample Clauses

PATIENT AGREEMENT. The information overleaf has been explained to me and I understand that treatment with GLP1 agonist will be stopped and alternative options considered if the beneficial effects on my weight and HbA1c are not achieved after 6 months or continued long-term.

PATIENT AGREEMENT. M OBILE PHONES I agree to switch off my phone before entering the building, and keep it turned off whilst in the building. REPEAT PRESCRIPTIONS I agree to request my medication 2 working days before I require it. I also agree to make my request either in person, post, online or on a slip provided. Please note we do not take requests over the telephone. A PPOINTMENTS I agree to attend my appointment on time. I acknowledge that if I arrive late for my appointment, I may be asked to re-book. If you have more than one problem you wish to discuss please ask the receptionist for a double appointment. When booking an appointment reception staff will ask for a reason. All staff have signed a confidentiality agreement. EMERGENCY APPOINTMENTS I agree to use these appointments for medical emergencies only. These are NOT to be used to request medication or fit notes. FIT NOTES Fit notes are at the discretion of the clinician.

PATIENT AGREEMENT. The undersigned applies for financial assistance indicated in this application and represents that all statements made in this application are true and are made for the purpose of obtaining financial assistance. The original or a copy of this application will be retained by the creditor, even if financial assistance is not granted. The undersigned also agrees to allow this facility to contact any or all of the above references for credit verification, including credit bureaus. Patient Signature Responsible Party or Spouse Signature Facility Representative Department Date

PATIENT AGREEMENT acknowledge and understand the above information.

PATIENT AGREEMENT a. Patient agrees that he or she will NOT submit a ▇▇▇▇ to a Medicare Carrier for treatment by Physician during the period of time in which Physician has elected to opt out of the Medicare Part B Reimbursement system, even though such treatment may be otherwise covered by Medicare. a. Patient agrees that he or she will not request Physician to submit a ▇▇▇▇ to a Medicare Carrier for treatment by Physician during the period of time in which Physician has elected to Opt out of the Medicare Part B Reimbursement system, even though such treatment may be otherwise covered by Medicare. c. Patient agrees that in return for treatment by Physician, Patient will receive a ▇▇▇▇ directly from Physician for professional medical services and items furnished by Physician and will be personally responsible for payment of such professional medical services and items directly to Physician.

PATIENT AGREEMENT. The information a bo ve has been explained to me and I understand that treatment with G L P 1 A go n i s t will be stopped and alternative options considered if the beneficial effects on my weight and HbA1c are not achieved after 6 months, or continued long-term.

PATIENT AGREEMENT. I acknowledge that there are proper methods of insertion and removal, and use and care of contact lenses. I understand there are associated risks with over wearing and improper use of contact lenses. I understand that if I should experience sudden or prolonged redness or irritation, I should call this office immediately. I understand that noncompliance may result in unsatisfactory service from contact lenses, and could result in injury to my eyes. I understand that follow up care is of optimum importance. I am required to complete the follow up care specified by my eye care physician prior to having my lens prescription finalized and released. And furthermore, I am aware of the importance of annual exams while wearing contact lenses.

PATIENT AGREEMENT. The information overleaf has been explained to me and I understand that treatment with: (Insert name of medicine) will be stopped and alternative options considered if the beneficial effects on my weight and HbA1c are not achieved after 6 months, or continued long-term. Today 6 month’s target Weight (3% loss needed by 6 months) HbA1c (11mmol/mol (1%) reduction needed by 6 months) eGFR (to check your kidney function) To be measured in 6 months Patient name ……………………………………………………………………. Patient signature ………………………………………………………………… Clinician name ……………………………………………………………………