Consent to Medical Treatment

Y & D Clinic

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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.

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