19+ Intake/Consent Form

Patient Information

Patient full name

Date of Birth

Sex

Preferred name

Street Address

City

State

Zip Code

Telephone Communication

Home phone # (or cell if that is your primary phone)

I give Omaha Children's Clinic P.C. permission to leave relevant, detailed telephone messages regarding my care and follow up, including test results, on my answering machine when I am not available. I do NOT give Omaha Children's Clinic P.C. permission to leave detailed telephone messages regarding my care when I am unavailable. I will return the phone call.

Cell phone #

I give Omaha Children's Clinic P.C. permission to text me appointment reminders regarding my upcoming appointments to the cell # shown above. I do NOT give Omaha Children's Clinic P.C. permission to text me appointment reminders. I prefer to be contacted by telephone.

Emergency Contact Information

Full name

Relationship to patient

Date of Birth

Full address

Home #

Cell #

Insurance Information

Insurance Company Name

Claims address

Phone #

Subscriber ID

Group #

Patient relationship to sbscriber

Subscriber's Name and Address

Subscriber's DOB

Notice of Privacy Practices Receipt of Acknowledgement and Consent for Treatment

My signature acknowledges I have been offered/received a copy of Omaha Children's Clinic P.C.'sHIPAA Privacy Practices for my review.

My signature also confirms I consent to medical care for myself at Omaha Children's Clinic, P.C, including all examinations, assessments, tests, therapy, outpatient diagnostic procedures including laboratory and radiology procedures, and other services and procedures that the physicians, other health care providers, and staff of this clinic deem necessary or appropriate. I understand the practice of medicine is not an exact science and no guarantees have been made to me regarding medical care.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date:

* This form is valid until revoked by patient or patient reaches the age of 22 *

Delegation of Consent

I hereby authorize the following individual(s) to consent to any and all medical care and attention deemed necessary and appropriate for me by a healthcare provider licensed in the state of Nebraska when I am unable to do so for myself. I also consent to clinic communications regarding my care with the individual(s) below. This consent includes, but is not limited to, medical and surgical intervention and elective as well as emergency care.This delegation shall be valid until I withdraw delegation of consent.

Add new row

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient Signature:

Date:

Witness:

Date:

Your information will be encrypted.