CONSENT FOR TREATMENT
I, the undersigned, consent to the care and treatment by the attending physician and his/her associates or assistants.
FINANCIAL RESPONSIBILITY AGREEMENT
I understand the treatment includes customary procedures such as blood draw, X-ray, incision and drainage, suturing, splinting and others.
I acknowledge that no guarantees have been made as to the effect of such treatment.
I acknowledge full financial responsibility for any service rendered and I understand that the payment of charges incurred in this office is due at the time of service.
I assign insurance benefits to this office, and I also understand that the charges not covered by insurance remain my responsibility. Patients may be entitled to financial assistance to cover all or some of the costs of care. To qualify, please reach out to our billing department to determine your eligibility.