As evidenced by my signature below, I voluntarily consent to receive outpatient medical care from the providers and medical staff at North Georgia Urology Center, P.C. (henceforth, the “Medical Practice”), including routine examinations, diagnostic procedures, and other medical treatment, including any requisite laboratory work and the administration of prescribed medications. In connection with such treatment, I understand and agree to each of the following:

Consent for Treatment of Minors

If the Medical Practice is treating my minor child, I am signing this Consent to Treatment on his/her behalf in the capacity of his/her parent or legal guardian. I further understand that the Medical Practice requires a parent or guardian to accompany a minor to all appointments. If, however, a parent or guardian is unable to accompany a minor to an appointment, they must provide verbal consent for treatment beforehand and designate an individual(s) to make financial arrangements/payments on the minor child’s behalf. The Medical Practice reserves the right to request the identification of any individual accompanying a minor.

1. The Medical Practice may file for insurance benefits to pay for the care I receive, and I am personally responsible for my share of the costs and/or any costs of services not covered by my insurance.
2. I have the right to refuse any procedure or treatment.
3. I have the right to discuss all medical treatments with my clinician.
4. No guarantees have been made to me as to the effect of any examinations or medical treatment I receive at the Medical Practice.

Authorized Parties: