Patient Consent Form

Consent to Treat

I am the guardian of

I have the legal right and responsibility to obtain and consent to medical and surgical treatment for this patient. I voluntarily authorize and consent to such medical care, treatment, and diagnostic tests that

Dr.

or her designated associates believe are necessary for this child. I understand that by signing this form, and by bringing this child to this medical office for care, I am giving permission tot he doctors and other heath care providers in this office to provide treatment to this patient as long as he/she is a patient of this practice.

Delegation of Consent

I hereby authorize (when I am unavailable to give consent) the following individual(s)

whose relationship to this patient is

to consent to any and all medical care and attention for this child which is deemed necessary and appropriate by a healthcare provider licensed in the State of Texas. This consent includes medical and surgical intervention, and elective as well as emergency care. This delegation shall be valid until I withdraw this delegation of consent.

Parent/Guardian Name

Relationship to Patient

Date

Witness

_______________________________________________________________________________________________

Written acknowledgement of receipt of notice of privacy practices

By signing below, you acknowledge receiving the Town Center Pediatrics Notice of Privacy Practices ("Notice"). The Notice explains how, Town Center Pediatrics may use and disclose your child's protected health information for treatment, payment, and health care operations purposes. "Protected health information" means your child's personal health information found in his/her medical and/or billing records. Your signature below only acknowledges that you have RECEIVED the Notice. If you have questions about the Notice, please contact the Privacy Officer for the office.

Patient's Name

Patient's Representative

Relationship of Representative to Patient

Date

_______________________________________________________________________________________________

Guarantor's statement of responsibility

I have received a copy of the practice's financial policy and understand that I am personally responsible for the payment of this patient's account.

Guarantor's Name

Date

Name of Responsible Party

Relationship to Patient

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