Consent Forms- Please call the office with any questions

Welcome to our office!

Patient's Name

Your Name

Patient's Date of Birth

General Consent to Treat

I am the parent or guardian of the above named minor.. I have the legal right to consent to medical and surgical treatment for this patient. I voluntarily authorize and consent to the medical care, treatment and diagnostic tests that Neighborhood Pediatrics and its designated associates or assistants believe are necessary for this child. I understand that by signing this form, I am giving permission to the doctors, nurses, physician assistants and other healthcare providers in this medical office to provide treatment to this child as long as this child is a patient in this office, or until I withdraw my consent.

Consent to Release and Obtain Information

In agreement with federal and state law, I agree to allow Neighborhood Pediatrics to deliver the necessary care to this child in order to provide continuity of care and treatment. Neighborhood Pediatrics and/or the patient’s provider may obtain from any source and examine use, or discuss and disclose, the patient’s medical record and information to treating hospital personnel and agents, other healthcare providers, medical records auditors, professional committees, care evaluators and governmental agencies. This information can include, but is not limited to: medical history, examinations, diagnoses, treatments any psychiatric, drug and alcohol abuse or genetic testing information, or HIV or AIDS information. This consent to release and obtain information is valid until revoked. The undersigned may revoke the consent in writing at any time, except with regard to disclosures that have already been made in reliance on such consent.

Electronic Prescriptions (E-Prescribing)

I voluntarily authorize Neighborhood Pediatrics to allow E-Prescribing for the patients mail order and traditional prescription, which allows healthcare providers to electronically transmit prescriptions to the pharmacy of my choice, review pharmacy benefit information and medical dispense history as long as this child is a patient at this office, or until I withdraw my consent.

CONSENT FORM FOR TAKING YOUR CHILD’S PHOTO TO BE PLACED IN THE PATIENT CHART FOR NEIGHBORHOOD PEDIATRICS

I give my permission for my child’s photo to be used in the patient chart. This picture will only be used for internal records. I can request that my child’s picture be removed from the chart at any time.

Final Acknowledgement

I have read this form or this form has been read to me in a language that I understand, and I have had an opportunity to ask questions about it.

Date

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Neighborhood Pediatrics

At Neighborhood Pediatrics we offer comprehensive care for your children. Please give us a call to schedule your appointment to discuss your child and any concerns you may have.

832-813-5743
www.neighborhoodpediatrics.com
19221 I-45S Suite 430, Shenandoah, TX, 77385, United States