OTHER CONCERNS / ROS
CONSENT / FOLLOW UP INFORMATION
For follow-up,such as lab results,X-ray reports,or billing matters,I prefer AHP to notify me by phone or email at: If AHP cannot reach me by phone, I authorize AHP to leave a detailed message about the care of the patient.I certify that the above information is true and I consent to any medical or surgical treatment rendered to the patient under the general or special instructions of the physician.I understand I may review in detail AHP's Privacy Practices. I am aware of my right to request special privacy considerations.
Birth History: Wgt. Problems .