I hereby give my consent to Lawndale Medical Clinic and authorize them to provide my medical treatment and procedure. I understand that Lawndale Medical Clinic will explain my condition(s), foreseeable risks, and methods of treatment for my condition before treatment and/or procedure is provided. I authorize Lawndale Medical Clinic to perform any additional or different treatment and or procedure that is thought necessary if, in an emergency situation, a condition is discovered that was not known previously.
I have carefully read and I fully understand this Patient Consent to Treat and Procedure form and will have the opportunity to discuss my condition and the procedure(s) with the care provider. All my questions well be adequately answered.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
Por medio de esta forma Yo doy mi consentimiento y autorization a Lawndale Medical Clinic de proveer mi tratamientoy procedimiento medico. Yo entiendo que Lawndale Medical Clinic me explicara mi condicion(es) medica, riesgos previsibles, y metodos para tratar mi condicion antes de recibir el tratamiento o procidimiento. Yo autorizo a Lawndale Medical Clinic de realizar cualquier otro tratamiento o procedimiento adicional si es necesario en aso de alguna situacion de emergencia que se descubriera una condicion medica que no se conocia anteriormente.
Yo cuidadosamente lei y entiendo completamente esta forma de Consentimento de Tratamiento y Procedimiento. Yo tendre la opotunidad de hablar con mi proveedor medico sobre mi condicion(es) medica y procedimientos necesarios. Todas mis pregustas seran adecudamente respondidas.
DESCARGO DE RESPONSABILIDAD: Al escribir su nombre a continuación, está firmando esta solicitud electrónicamente. Acepta que su firma electrónica es el equivalente legal de su firma manual en esta aplicación.
I have reviewed this office Notice of Privacy Practices, which explain how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.
Yo he revisado la notifcation de Practica Privada, la cual explica como mi information medica sera utilizada y revelada. Yo entiendo que tengo derecho de recibir una copia de este documento.
Yo autorizo a Lawndale Medical Clinic y a su personal de evaluar y tratar a, que es un menor de edad, el o la doctora determinara por su juicio lo mejor para el bienestar de su hijo (a).
I give consent for the person/persons listed below to assume my responsibilities as guardian and accompany my child to your facility, as needed. (Yo, doy consentimiento a la persona/personas nombradas abajo de asumir mi responsabilidad como tutor y de acompanar a mi hijo/hija a la clinica cuando sea necesario.)
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Telemedicine services involve the use of secure interactive videoconferencing equipment and devices that enable health care providers to deliver health care services to patients when located at different sites.
By signing this form, I attest that I (1) have personally read this form (or had it explained to me) and fully understand and agree to its contents; (2) have had my questions answered to my satisfaction, and the risks, benefits, and alternatives to telemedicine visits shared with me in a language I understand; and (3) am located in the State of Texas and will be in Texas during my telemedicine visit(s).
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