Healthcare Clinic Waivers

HEALTHCARE CLINIC WAIVERS

Clinic Name:    Patient Name:

Patient Information

Insurance Information

Medical History

Consents and Waivers

Consent to Treatment: I hereby authorize clinicians and authorized staff of the clinic to perform examinations, diagnostic tests, and treatments as deemed necessary for my care. I understand that no guarantee has been made as to the results of any treatment. I acknowledge that the nature, benefits, risks, and alternatives have been explained to my satisfaction.

I consent to the above treatment terms and authorize care.

Financial Responsibility: I agree to be financially responsible for all charges not fully covered by third-party payers. I authorize release of any information necessary to process claims and authorize payment of benefits to the clinic for services rendered.

I acknowledge and accept financial responsibility.

HIPAA Privacy Acknowledgement: I have received and acknowledge the clinic's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I understand my rights regarding my health information, including the right to request restrictions and the right to receive confidential communications.

I acknowledge receipt of the Notice of Privacy Practices.

Authorization to Leave Messages: The clinic may leave appointment reminders, test results, and billing information on my voicemail or with the individual answering my telephone number.

I authorize voicemail/telephone communications.

Release of Medical Records

I authorize the clinic to release my medical records or protected health information to the person(s) or entity(ies) named below for continuity of care or billing purposes. This authorization is voluntary and may be revoked in writing, except to the extent action has already been taken in reliance on it.

Assumption of Risk and Release of Liability

I understand that certain treatments, procedures, examinations, or activities at the clinic carry inherent risks and potential complications. To the fullest extent permitted by law, I hereby release and hold harmless the clinic, its employees, contractors, and agents from any liability for personal injury, property damage, or death that may arise from my participation in treatments or services, except where caused by gross negligence or willful misconduct.

I accept the assumption of risk and release the clinic as set forth above.

Photography / Video Consent (Optional)

I authorize the clinic to take photographs or video recordings for treatment documentation, education, or promotional use. I may restrict use of images or recordings by indicating limitations below.

I consent to photography/video as described.

Telehealth Consent (If Applicable)

If receiving care via telehealth, I understand the benefits and limitations of remote clinical services. I consent to the use of telecommunication technologies for assessment, diagnosis, and treatment when recommended by my clinician.

I consent to telehealth services when appropriate.

Minor Patient / Guardian Information

If the patient is a minor or unable to consent, the guardian or authorized representative must complete the following. By signing this form, the guardian represents they are authorized to make medical decisions on behalf of the patient.

Certification

I certify that the information contained on this form is true and correct to the best of my knowledge. I understand this document authorizes the actions described herein and that I may revoke authorizations in writing except to the extent that action has already been taken in reliance on them. I acknowledge I have had the opportunity to ask questions and have those questions answered.

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