Common Contracts
1 similar Consent for Treatment/Financial Agreement contracts
Consent for Treatment/Financial AgreementConsent for Treatment/Financial Agreement • November 18th, 2020
Consent for Treatment/Financial Agreement: I consent to treatment necessary or desirable to the care of the patient first mentioned above, including but not restricted to, whatever drugs, medicine, performance of operations and conduct of laboratory, x-ray or other studies that may be used by the attending doctor, his nurse or qualified designate. I also acknowledge full responsibility for the payment of all services, and agree to pay all amounts due in full at the time of service. I understand that the patient or responsible party is solely responsible for payment of all services, though the insurance may be filed. If this account becomes delinquent, I agree to pay all costs of collection, including a reasonable attorney's fee. I understand that I will be charged $32.00 for any returned check.
