ReviveMD requires each patient (or an authorized representative) to sign this Consent to Treatment form prior to receiving examination, care and treatment from a ReviveMD provider. An “authorized representative” may be a parent, legal guardian, or Health Care Proxy.
By my signature below, I voluntarily consent to examination, care and treatment by ReviveMD health care providers and/or their designated assistants (ReviveMD Staff).
I understand that in the course of caring for me, ReviveMD Staff may discover conditions that may require additional testing, procedures, treatments and/or referrals that were not initially planned. I hereby authorize ReviveMD Staff to perform such additional testing, procedures and/or treatments, and make such referrals, that are advisable in their medical judgment. I consent to medical photographs being placed into my medical record. I understand that if certain testing, procedures or treatments are recommended, I will have an opportunity to discuss the treatment plan with my provider and I will be asked to read and sign additional specific consent forms prior to receiving such test(s), procedure(s) and/or treatments.
I acknowledge that no guarantees have been made to me as to the effect of any examination, care or treatment performed by Prima CARE Staff. Any questions I have about this Consent to Treatment Form and its contents have been answered to my satisfaction.