Consent for Treatment & Financial Agreement - SMJH & SMJMGConsent for Treatment & Financial Agreement • February 6th, 2019
CONSENT FOR TREATMENT: Martha Jefferson Hospital; d/b/a Sentara Martha Jefferson Hospital or Martha Jefferson Medical Group, LLC. (“Sentara”) accepts the above Patient for diagnostic testing, emergency or inpatient/outpatient treatment/surgery or telehealth services. The undersigned hereby consent(s) to Sentara providing its standard services, telehealth services and supplying or administering all services, supplies, medications (which may be dispensed from an alternate site pharmacy) and anesthesia ordered by Patient’s or Sentara’s physicians/assistants, and to the performance of all procedures they deem advisable, and to the disposal of removed tissues and the use of photography for clinical purposes.
ContractConsent for Treatment & Financial Agreement • July 18th, 2018
CONSENT FOR TREATMENT: Pratt Medical Center, Ltd. (DBA: Pratt Healthcare) accepts the below-named patient for outpatient treatment and treatment and diagnostic testing. The Undersigned hereby consents to Pratt Medical Center, Ltd. providing its standard services.
Consent for Treatment & Financial AgreementConsent for Treatment & Financial Agreement • September 24th, 2019
ContractConsent for Treatment & Financial Agreement • July 18th, 2018
CONSENT FOR TREATMENT: Pratt Medical Center, Ltd. (DBA: Pratt Healthcare) accepts the below-named patient for outpatient treatment and treatment and diagnostic testing. The Undersigned hereby consents to Pratt Medical Center, Ltd. providing its standard services.
Consent for Treatment & Financial AgreementConsent for Treatment & Financial Agreement • May 25th, 2018
CONSENT FOR TREATMENT: Martha Jefferson Hospital; d/b/a Sentara Martha Jefferson Hospital or Martha Jefferson Medical Group, LLC. (“Sentara” or “Hospital”) accepts the above Patient for diagnostic testing, emergency or inpatient/outpatient treatment/surgery or telehealth services. The undersigned hereby consent(s) to Sentara providing its standard services and supplying or administering all services, supplies, medications and anesthesia ordered by Patient’s or Sentara’s physicians/assistants, and to the performance of all procedures they deem advisable, and to the disposal of removed tissues and the use of photography for clinical purposes.
Consent for Treatment & Financial AgreementConsent for Treatment & Financial Agreement • June 20th, 2021
Patient LabelConsent for Treatment & Financial Agreement • May 1st, 2018
CONSENT FOR TREATMENT: Sentara Medical Group accepts the below-named patient for outpatient treatment and diagnostic testing. The undersigned hereby consents to Sentara Medical Group providing its standard services.
Consent for Treatment / Financial AgreementConsent for Treatment / Financial Agreement • October 23rd, 2014
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.
