Consent to Treat

I consent to medical care—including recommendations for any treatments, procedures, or lab work—at Mertz MFM Center.
You have the right, as a patient, to be informed about your condition and the recommended medical or diagnostic procedure to be performed so that you may make the decision whether to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s).

This consent provides us with your permission to perform reasonable and necessary medical examinations, testing, and treatment. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

You have the right to discuss the treatment plan with your physician about the purpose, potential risks, and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to bring this to our attention and ask questions.

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents. By using an electronic signature, I demonstrate my acceptance of the statements above. My electronic signature is as legally binding as my handwritten signature.

If you authorize us to provide follow-up notes on your consultation to your other primary providers

Patient or Guardian (where applicable) Signature

Please sign electronically below.

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Click submit and you hereby give consent to sign this document electronically.

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