Johns Creek Vickery Village | Patient Consent Form

(PLEASE READ AND INITIAL THE FOLLOWING)
I, the undersigned, hereby consent to the following treatments. • Administration and performance of all treatments • Administration of any needed anesthetics • Performance of such procedures as may be deemed necessary or advisable in the treatment of this patient. • Performance of diagnostic procedures/test and cultures • Performance of other medically accepted laboratory tests that may be considered medically necessary or advisable based on the judgment of the attending physician or their assigned designees.
Initials*
I fully understand that this is given in advance of any specific diagnosis or treatment
Initials*
I intend this consent to be continuing in nature even after specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing.
Initials*
I understand that Dr. Steenlage, will include consent at satellite offices under common ownership
Initials*
I, the undersigned, authorize Dr. Steenlage, to use and disclose my information for the purposes of treatment, payment and healthcare operations as described in the Notice of Privacy Practices. A photocopy of this consent shall be considered as valid as the original.
Initials*
MEDICARE PATIENTS: I authorize the release of medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to Eric S. Steenlage, MD.
Initials*
There will be a $25.00 charge for all FMLA, medical records, or any other paperwork that is requested to be filled out by medical personnel. Please allow one week for all request to be fulfilled.
Initials*
By my signature below I acknowledge that I have been informed by Dominion Orthopaedic Clinic LLC, and/or my Physician may utilize an Associate Physician and/or Physician Assistant for medical services rendered. I have further been informed that as a courtesy , my insurance will be billed for these services and any balance will be my responsibility.
Patient (or Responsible Party) Name*
Date*
I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Johns Creek Vickery Village | Patient Consent Form

Johns Creek Vickery Village | Patient Consent Form

(PLEASE READ AND INITIAL THE FOLLOWING)