We encourage all patients to complete an advance directive, which allows you to state your preferences for medical treatments and to select an agent or person to make your health care decisions in case you are unable to do so or if you want someone else to make decisions for you. Further information on advance directives is available on our web site www.pancarefl.org.
If you already have an advance directive, please bring a copy with you at your next visit. Your advance directive will be placed in your medical record. However, PanCare is not set up to make a medical determination as to the cause of an emergent situation that may present and/or occur at any of our clinics. In the event of an emergent situation, our staff will call 911 and defer the advance directive protocol to the acute hospital setting.
I have initialed the Broken Appointment and Confirmation Policy Agreement, Release of Medical/Dental/Behavioral Health Information, Notice of Privacy Practices/Patient Rights and Responsibilities, Consent for Treatment, Non-Covered Insurance Services, and Advance Directives. By doing so I acknowledge that I have read all of the aforementioned statements and will abide by the same and if I do not this may disqualify me from receiving care from PanCare Health Medical/Dental Clinics.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.