General Consent for Care and Treatment

TO THE PATIENT: You have the right to be informed about your condition and about the recommended medical treatments, surgical, and diagnostic procedures so that you may make a confident decision to decline or accept any suggested medical treatments, surgical, and diagnostic procedures after knowing the potential risks and hazards involved. As a new patient, there is no specific treatment plan recommended. This consent form is to provide The Vanderbilt Wellness Clinic permission to perform the evaluation necessary to begin your care here. 

PERMISSIONS: By signing this consent form, The Vanderbilt Wellness Clinic and its staff are granted your permission to perform reasonable and necessary medical examinations, testing, and treatment. This consent is continuing in nature even after a specific diagnosis has been made and treatment recommended and provided. This consent will remain fully effective until revoked in writing and you have the right to do so at any time. 

You, the patient, have the right to discuss any and all recommended medical examinations, testing, and treatment proposed to you by The Vanderbilt Wellness Clinic and its staff for the condition you are seeking care for. Additional consent will need to be signed prior to any recommended invasive or interventional procedures.

I have read this consent form and certify that I fully understand, agree, and voluntarily consent to its content and statements. 

________________________________________________________________

Patient’s Full Legal Name (Printed)

________________________________________________                                                ______________

Patient or Legal Representative’s Signature                                                                      Date

___________________________________________                                                           ____________________

Legal Representative’s Name if Applicable (Printed) Relationship to Patient                 Date

___________________________________________               ____________________

Witness’ Name (Printed) Witness’ Role                                    Date

________________________________________________      ______________

Witness Signature                                                                       Date