Procedure(s) and services provided may include but not limited to physical examination, vaccination administration, phlebotomy, medication prescribing and administration, and I will be provided with the necessary information needed to evaluate the risks and benefits of the proposed Procedure(s). I will also receive information regarding: (a) the nature and purpose of the proposed Procedure and related care, treatment, services, medications, and interventions; (b) alternatives to the Procedure(s), as well as the relevant risks and benefits of such alternative procedure(s); (c) clinical outcome if I do not elect to have the proposed Procedure(s); (d) the potential benefits and possible risks, side effects and complications associated with the Procedure(s); and (e) the likelihood of achieving care, treatment and service goals. I understand that the Practice’s Privacy Notice describes any limitations on the confidentiality of patient information.
I acknowledge that no guarantees or assurances have been given to me by anyone as to the results that may be obtained from the Procedure or other diagnostic tests.
I confirm that I have read and fully understand the above and that all the blank spaces have been completed prior to my signing. I have been given an opportunity to ask questions and all my questions have been answered fully and satisfactorily.