I, or authorized representative acting on behalf of the patient, or as a parent or legal guardian of the patient, do hereby consent to receiving general medical services, which may include routine diagnostic procedures and such medical treatment as the physician, his/her assistants or his/her designees consider to be necessary in his/her judgment. I also acknowledge that the practice of medicine is not an exact science and that no guarantees have been made to me as the results of treatments or examination at Youens & Duchicela Clinic.
Acknowledgement of Review of Notice of Privacy Practices
I have reviewed Youens and Duchicela Clinic's Notice of Privacy Practices, which explains how my medical information will be used and disclosed. I understand that I am entitled to receive a copy of this document.
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.