Patient Name (last, first, MI): Date of Birth (mm/dd/yyyy): Medical Record #:July 27th, 2020
FiledJuly 27th, 2020As either the Patient or the legally authorized representative of the Patient, on behalf of the Patient receiving care in this Physician Group of Arizona, Inc., (PGA) Facility, I make the following consents, understandings, and agreements on my own behalf and on behalf of the Patient in partial consideration of health care services to be provided to the Patient in the PGA Facility, including IASIS Healthcare and its affiliates.