ALLIANCE PRIMARY CARE OF NJ
JOYCE NKWONTA, MD,PC
1314 PARK AVENUE, SUITE 1, PLAINFIELD, NJ 07060
Consent for Routine Diagnosis and Treatment
I have come to Alliance Primary care of NJ, Joyce Nkwonta, MD, to voluntarily seek medical care and services that may include routine diagnosis and treatment procedures. This consent will govern the performance of routine diagnostic and treatment procedures such as physical examination, blood drawing and other routine non-invasive procedures. I fully understand that results of service(s) I receive is (are) not guaranteed. Furthermore, I acknowledge that this consent will remain valid until I explicitly revoke it.
Consent to obtain External Prescription History
I authorize Dr. Joyce Nkwonta, Alliance Primary Care of NJ, to obtain a list of my medications from ALL pharmacies that I go to. The medication history will include all controlled and non-controlled medications that I am taking or have taken or filled.
New Jersey State Immunization Registry
I authorize Dr. Joyce Nkwonta, Alliance Primary care of NJ, PC, to share and access my immunization records from the New Jersey State registry.
Please inform receptionist if you do not wish to share this information.
Privacy Notice (HIPPA)-viewed on our website.
I have read and fully understand the notice regarding our Privacy Practices.
Office and Financial Policies
I have read, fully understand and consent to the office and financial policies.
Signature on File
I understand that I am responsible for all treatment not covered by my insurance and failure to remit payment can and will result in forwarding my account to collections.
My signature below indicates that all information provided on pages 1 and 2 of this registration and consent forms are true and accurate.