CONSENT FOR TREATMENT
I, the undersigned, consent to the care and treatment by the attending physician and his/her associates or assistants.
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.
FINANCIAL RESPONSIBILITY AGREEMENT
I acknowledge full financial responsibilty 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.