Consent for Treatment Form

I authorize my healthcare provider to discuss my health information with the following family member(s):

Authorized family member name(s):

Relationship(s):

I require an interpreter for healthcare appointments

Preferred language for interpretation:

I understand and accept my financial responsibilities as outlined above *

I acknowledge that I have read and understand my rights and responsibilities as a patient *

I have received and read the clinic's Privacy Policy *

I have had the opportunity to ask questions about this consent form *

I understand that I can withdraw my consent at any time, except where already acted upon *

I am giving this consent voluntarily and without coercion *

Patient Signature (or Legal Guardian if patient is minor): *

Date: *

Print Name: *

Relationship to Patient (if not patient):

Witness Signature (if required):

Date:

Witness Print Name:

Healthcare Provider Name:

Date Reviewed with Patient:

Provider Signature:

Notes: