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CONSENT FOR TREATMENT*
I, the undersigned, consent to the care and treatment by the attending physician and his/her associates or assistants. I understand the treatment includes customary procedures such as noting medical history, checking recent medical reports, if available. I acknowledge that no guarantees have been made as to the effect of such information. The doctor shall make an informed call based on available medical history, reports, his/ her diagnosis.
I, the undersigned, consent to the care and treatment by the attending physician and his/her associates or assistants. I understand the treatment includes customary procedures such as noting medical history, checking recent medical reports, if available. I acknowledge that no guarantees have been made as to the effect of such information. The doctor shall make an informed call based on available medical history, reports, his/ her diagnosis.
FINANCIAL RESPONSIBILITY AGREEMENT*
I acknowledge full financial responsibility for any service rendered and I understand that the payment of charges incurred is due at the time of service. I assign insurance benefits to Jeevandan Health and I also understand that the charges not covered by insurance remain my responsibility.
I acknowledge full financial responsibility for any service rendered and I understand that the payment of charges incurred is due at the time of service. I assign insurance benefits to Jeevandan Health and I also understand that the charges not covered by insurance remain my responsibility.