BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THESE DOCUMENTS:Consent and Financial Agreement • February 10th, 2017
● 2017 CERTIFIED DERMATOLOGISTS CONSENT, FINANCIAL AGREEMENT, CONSENT TO TREATMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION
Consent, Financial Agreement and Office PoliciesConsent and Financial Agreement • May 17th, 2017
The undersigned authorizes the medical providers at NorCal Endocrinology & Internal Medicine to provide medical, surgical and laboratory and radiology services deemed necessary for the treatment of illness or injury. The undersigned also authorizes the medical providers at NorCal Endocrinology & Internal Medicine to provide emergency medical treatment in the event of a medical emergency when the undersigned is unable to personally consent to treatment. The undersigned also agrees to be responsible for any charges associated with this emergency care including, but not limited to, transporting patient to the nearest hospital.
BY SIGNING BELOW, I ACKNOWLEDGE THAT I HAVE READ AND UNDERSTAND THESE DOCUMENTS:Consent and Financial Agreement • April 9th, 2022
● 2022 CERTIFIED DERMATOLOGISTS CONSENT, FINANCIAL AGREEMENT, CONSENT TO TREATMENT AND AUTHORIZATION FOR RELEASE OF INFORMATION
CONSENT AND FINANCIAL AGREEMENTConsent and Financial Agreement • December 15th, 2020
All patients must read and sign form prior to receiving services)Consent and Financial Agreement • September 3rd, 2022
Thank you for choosing SMART Sports Medicine Center as you healthcare provider. We are dedicated to providing the best possible healthcare and rehabilitation to you, our patient. As a part of our professional relationship, it is important that you understand our consent, financial and HIPAA agreement.
