As a pateint of Advanced Family Foot and Ankle I hereby request and authorize the physicians and staff to provide me with the recommended medical, diagnostic, and surgical treatment as they deem necessary.
I am aware that the practice of medicine is not an exact science and I acknowledge that NO guarantees have been made to me as a result of any medical examinations or treatments. I am also aware that in the practice of medicine other unexpected risks or complications not discussed may occur. I also understand that during the course of any proposed procedures or treatment, unforseen conditions may be revealed requiring the performance of additional procedures. If addition procedures are required in non-emergency circumstances I will be provided with additional educational information so I may make an informed decision. Additional consent fors may be provided to me.
I understand that all information pertaining to my care will remain a confidential part of my medical record as it relates to the Health Insurance Portability and Accountability Act.