CONSENT FOR MEDICAL TREATMENT

 

Patient Name:

Date of Birth:

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I consent to the treatment that will be provided by WELLNESS FAMILY HEALTH NP PRACTICE P.C. primary care providers, as well as their assistants and other staff members. I understand that a medical record will be prepared and maintained about me by WELLNESS FAMILY HEALTH NP PRACTICE P.C. and that I am entitled to obtain a copy of my medical record by signing a Medical Records Authorization Form provided by WELLNESS FAMILY HEALTH NP PRACTICE P.C. for that purpose.