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In consideration of services provided by Neurological Institute for Concussion & Headache (“Provider”), the Patient or undersigned representative acting on behalf of the Patient agrees and consents to the following:

  1. Consent to Routine Medical Treatment/Services. Patient consents to the rendering of Medical Treatment/Services as considered necessary and appropriate by the attending physician or other practitioner, a member of the Provider’s medical staff who has requested care and treatment of Patient, and others with staff privileges at Provider. Medical Treatment/Services may be performed by "Healthcare Professionals" (physicians, radiologist, nurses, technologists, technicians, physician assistants or other healthcare professionals). Patient authorizes the attending or other practitioner, the medical staff of Provider and Provider to provide Medical Treatment/Services ordered or requested by attending or another practitioner and those acting in his or her place. The consent to receive “Medical Treatment/Services” includes but is not limited to: out-patient care; examinations (MRI, x-ray or otherwise); laboratory procedures; medications; drugs; supplies; anesthesia; surgical procedures and medical treatments; recording/filming for internal purposes (Patient’s name, identification, diagnosis, treatment, performance improvement, education, safety, security) and other services which Patient may receive. Patient consents to treatment by Provider with the understanding that Patient will furnish accurate information regarding their injuries and will cooperate when referred to other physicians or medical facilities for examination or testing. Patient’s non-compliance with the plan of treatment may result in the refusal of further care and discharge from Provider.
  2. Legal Relationship between Facility and Physician. Neurological Institute for Concussion & Headache is physician owned facility and your physician may have a financial interest in the center. Patient has the right to choose where Patient receives medical and surgical services including an entity in which Patient’s physician may have a financial relationship. Patient will not be treated differently by Patient’s physician if Patient opts to use a different facility. If desired, Patient’s physician can provide information about alternative providers. By accepting this acknowledgment of disclosure, Patient acknowledges that Patient has read and understand the foregoing notice regarding physician ownership.
  3. Explanation of Risk and Treatment Alternatives. Patient acknowledges that the practice of medicine is not an exact science and that NO GUARANTEES OR ASSURANCES HAVE BEEN MADE TO THE PATIENT concerning the outcome and/or result of any Medical Treatment/Services. While routinely performed without incident, there may be material risks associated with each of these Medical Treatment/Services. Patient understands that it is not possible to list every risk for every Medical Treatment/Services and that this form only attempts to identify the most common material risks and the alternatives (if any) associated with the Medical Treatment/Services. Patient also understands that various Healthcare Professionals may have differing opinions as to what constitutes material risks and alternative Medical Treatment/Services. By signing this form: Patient consents to Healthcare Professionals performing Medical Treatment/Services as they may deem reasonably necessary or desirable in the exercise of their professional judgment, including those Medical Treatment/Services that may be unforeseen or not known to be needed at the time this consent is obtained; and Patient acknowledges that Patient has been informed in general terms of the nature and purpose of the Medical Treatment/Services; the material risks of the Medical Treatment/Services and practical alternatives to the Medical Treatment/Services. The Medical Treatment/Services may include, but are not limited to the following:
  4. a)  Needle Sticks, such as shots, injections, intravenous lines or intravenous injections (lVs). The material risks associated with these types of Procedures include, but are not limited to, nerve damage, infection, infiltration (which is fluid leakage into surrounding tissue), disfiguring scar, loss of limb function, paralysis or partial paralysis or death. Alternatives to Needle Sticks (if available) include oral, rectal, nasal or topical medications (each of which may be less effective).
  5. b)  Physical Tests, Assessments and Treatments such as vital signs, internal body examinations, wound cleansing, wound dressing, range of motion checks and other similar procedures. The material risks associated with these types of Procedures include, but are not limited to, allergic reactions, infection, severe loss of blood, muscular-skeletal or internal injuries, nerve damage, loss of limb function, paralysis or partial paralysis, disfiguring scar, worsening of the condition and death. Apart from using modified Procedures, no practical alternatives exist.
  6. c)  Administration of Medications via appropriate route whether orally, rectally, topically or through Patient’s eyes, ears or nostrils, etc. The material risks associated with these types of Procedures include, but are not limited to, perforation, puncture, infection, allergic reaction, brain damage or death. Apart from varying the method of administration, no practical alternatives exist.
  7. d) Insertion of Internal Tubes such as bladder catheterizations, nasogastric tubes, rectal tubes, drainage tubes, enemas, etc. The material risks associated with these types of Procedures include, but are not limited to, internal injuries, bleeding, infection, allergic reaction, loss of bladder control and/or difficulty urinating after catheter removal. Apart from external collection devices, no practical alternatives exist.
  8. e)  Radiological Studies such as X-rays or MRI scans. The material risks associated with these types of Procedures include, but are not limited to, radiation exposure.

If Patient has any questions or concerns regarding these Medical Treatment/Services, Patient will ask Patient’s attending provider to provide Patient with additional information. Patient also understands that Patient’s attending or other provider may ask Patient to sign additional informed consent documents concerning these or other Medical Treatment/Services.

  1. Healthcare Practitioners in Training. Patient recognizes that among those who may attend to Patient at Provider’s offices/clinics are medical, nursing and other health care personnel who are in training and who, unless specifically requested otherwise, may be present and participate in patient care activities as part of their medical education. There also may be present from time to time a medical product or medical device representative. Consent is hereby given for the presence and participation of such persons as deemed appropriate by the attending physician.
  2. Authorization to Release Information. Provider is authorized to release information contained in the patient record. The information authorized to be released shall include, but is not limited to, infectious or contagious disease information, including HIV or AIDS-related evaluations, diagnosis or treatment; information about drug or alcohol abuse or treatment of same and/or psychiatric or psychological information. Patient waives any privilege pertaining to such confidential information. SIS, its agents and employees are hereby released from any and all liabilities, responsibilities, damages, claims and expenses arising from the release of information as authorized above. Reasons for releasing a Patient’s record include, but are not limited to, insurance company(s), their agents or other third party payor and/or government or social service agencies which may or will pay for any part of the medical/hospital expenses incurred or authorized by representatives of SIS, as mandated by law, or to alternate care providers, including community agencies and services, as ordered by Patient’s physician or as requested by Patient or Patient’s family for post-hospital care. PATIENT ACKNOWLEDGES AND AGREES THAT PATIENT’S RECORDS WILL BE AVAILABLE TO ALL OF PROVIDER’S AFFILIATED ENTITIES AND PROVIDERS, AND TO NON-PROVIDER AFFILIATED REFERRING PROVIDERS IN COMPLIANCE WITH THE PROVISIONS OF MEANINGFUL USE. Patient also agrees, in order for Provider to service accounts or to collect liabilities owed, to receive contact by telephone at any telephone number associated with their record, including wireless telephone numbers, which could result in charges to Patient. Provider or its agents may also contact Patient by sending text messages or emails, using any email address Patient provides. Methods of contact may include using pre-recorded/artificial voice messages and/or use of an automatic dialing device, as applicable.

Validity of Form. Patient acknowledges that a copy, or an electronic version of this document may be used in place of and is as valid as the original. Patient understands that the Healthcare Professionals participating in the Patient’s care will rely on Patient’s documented medical history, as well as other information obtained from Patient, Patient’s family or others having knowledge about Patient, in determining whether to perform or recommend the Procedures; therefore, Patient agrees to provide accurate and complete information about Patient’s medical history and conditions.

Patient has read and understood and accepted the terms of this document and the undersigned is the Patient, the Patient’s legal representative or is duly authorized by the Patient as the Patient’s general agent to sign this form.  

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