CONSENT FOR TREATMENT

I hereby authorize Dr.Ashok Kumar Borkar to perform upon me medical treatment and or diagnostic/ therapeutic procedures as required in plan of treatment.

The nature and the purpose of procedure, the necessity, thereof the possible alternative methods, treatment prognosis have been fully explained to me and have been fully explained the possibility of complications of the investigative procedures / investigations and treatment of my condition/ diagnosis. I have been fully explained and we understand the same. I have been explained clearly that any medications / investigations is not totally safe and such procedures can risk life.

I have been given the opportunity to ask all questions and have also been given option to ask any second opinion.

I acknowledge that no guarantee and promises have been made to me concerning the result of any procedure or treatment.

Attendance and Appointments

• I agree to arrive on time for all scheduled appointments.
• I will provide at least 24 hours’ noticeif I need to cancel or reschedule an appointment.
• 2 or more missed appointments or late arrivals may result in forfeit the amount paid and discharge from care.

 Payment and Financial Responsibility

• I understand that all fees are due at the time of service, unless otherwise arranged.
• I am responsible for all charges not covered by insurance.
• I authorize the clinic to bill my insurance provider as applicable and to release necessary medical information for billing purposes, in case Insurance covers the treatment.

Honesty and Disclosure

• I agree to provide accurate and complete informationabout my medical history, medications, allergies, and symptoms.
• I will inform my practitioner of any changes in my health status during treatment.

Treatment Consent

• I understand that the proposed treatment(s) have been explained to me, including the benefits, possible risks, and alternatives.
• I consent to receive the agreed-upon treatment plan.
• I understand that I may withdraw consent at any time.

 Conduct and Respect

• I will treat all clinic staff and other patients with courtesy and respect.
• Any form of verbal abuse, harassment, or violencewill result in termination of care.
• I will comply with all clinic safety and hygiene rules.

 

 Confidentiality

• I understand that my personal and medical information will be kept confidentialin accordance with privacy laws.
• I authorize communication regarding my care only with those I have designated in writing.

Results and Responsibilities

• I understand that treatment outcomes vary and that no guarantees can be made regarding results.
• I agree to follow my practitioner’s advice regarding home care, medication, and follow-up appointments.

Emergency Policy

• I understand that this clinic does not provide emergency services, and I will seek emergency care (e.g., hospital or emergency number) in case of urgent or life-threatening situations.

Acknowledgment and Signature

I have read and understood the above rules and policies. I agree to comply with them and consent to receive treatment under these conditions.