213 Greenhill Ave. Wilmington, DE 19805
(302) 429-5870
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Family Medicine at Greenhill Patient Consent Form

l, the undersigned, hereby consent to the following treatment:

  • 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
  • Use of prescribed medication
  • Performance of diagnostic procedures/tests 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

I fully understand that this is given in advance of any specific diagnosis or treatment.

I intend this consent to be continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain in full force until revoked in writing.

I the undersigned authorized FAMILY MEDICINE AT GREENHILL 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.

MEDICARE PATIENTS: I authorize to release medical information about me to the Social Security Administration or its intermediaries for my Medicare claims. I assign the benefits payable for services to FAMILY MEDICINE AT GREENHILL.

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

Electronically Signed
I, the undersigned, acknowledge and agree that by typing my name, clicking “I Accept,” or by other electronic means, I am signing this document electronically.