Consent to Treat Form

I have the legal right to give consent to the medical treatment of this patient. I voluntarily authorize and consent to medical care, treatment, and diagnostic tests that In & Out Pediatrics believe is necessary for this child. I understand by signing this form, I am giving permission to the Pediatric Nurse Practitioner and medical assistant to provide treatment to this patient. During the course of my care and treatment, I understand that various types, diagnostic, or treatment procedures may be necessary. These procedures are performed by the Pediatric Nurse Practitioner. While usually performed without incident, there are potential risk associated with each of these procedures. It is not possible to list every risk for every procedure and this form will therefore list the most common possible risks. It is important to note that a simple act as taking a commonly used medication can rarely cause severe reactions that could lead to organ failure or even death. If I have any questions or concerns regarding these procedures, I will ask the Pediatric Nurse Practitioner to provide me with additional information. These procedures include needle sticks such as shots or injections. Material risks include, but are not limited to infection, disfiguring scar, nerve damage with possible loss of limb function. Alternatives to needle sticks (if available) include oral, rectal, nasal, or topical medications (each of which may be less effective) or refusal of treatment. Physical tests, assessments, and treatments such as internal body examinations, wound cleaning and wound dressing. Material risks include allergic reaction and infection. Apart from using modified procedure and/or refusal of treatment, no practical alternative exists. Administration of medication whether orally, rectally, topically, or through the eye, ear, or nose. Material risks include, but are not limited to, allergic reaction, puncture, and perforation. Apart from varying the method of administration and/or refusal of treatment, no practical alternative exists. I understand that the practice of medicine is not an exact science and that no guarantee or assurances have been made to me concerning the outcome and/or result of any procedures. The health care professional participating in my care will rely on my documented medical history, as well as other information obtained from me, my family, or others having knowledge about me, in determining whether to perform or recommend the procedures, therefore, I agree to provide accurate and complete information about my medical history. I may be asked to sign additional required informed consent documents for specific procedures and tests. By signing this form, I consent to the healthcare professional performing procedures as they deem reasonably necessary or desirable in the exercise of their professional judgment, including those procedures that may be unforeseen and not known to be needed at the time this consent is obtained. I acknowledge that I have been informed, in general terms, of the nature and purpose, the material risks and the practical alternatives of the procedures. I understand that In & Out Pediatrics uses a Pediatric Nurse Practitioner who has been approved by the Alabama State Board of Medical Examiners. Your signature on this approval form conveys that you are in agreement with being treated by our Pediatric Nurse Practitioner who act under the supervision of a Alabama Medical Board certified delegating physician.

*Patient's Name

*Email

*Agree to Terms

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