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SHARED ELECTRONIC HEALTH RECORDPatient Name: OUTPATIENT CONSENT TO TREAT Page 1 of 4MRN: DOB: I. CONSENT TO TREAT I, am I presenting myself/my to the outpatient facility, clinic or practice for a
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01
Obtain a copy of the outpatient consent to treat form.
02
Read the form carefully and understand its contents.
03
Fill in your personal information, including your name, date of birth, and contact details.
04
Provide details about your medical history, including any allergies, current medications, and previous surgeries.
05
Indicate the purpose of your visit and the specific treatment or procedure you are consenting to.
06
Sign and date the form to indicate your consent.
07
If applicable, include the name and contact information of your emergency contact person.
08
Review the completed form for accuracy and make any necessary corrections.
09
Return the signed form to the healthcare provider or designated staff member.
10
Keep a copy of the completed form for your records.

Who needs outpatient consent to treat?

01
Anyone seeking outpatient medical treatment or procedures.
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Outpatient consent to treat is a form that gives healthcare providers permission to treat a patient on an outpatient basis.
The patient or their legal guardian is required to file outpatient consent to treat.
Outpatient consent to treat can be filled out by providing personal information, medical history, and signing the form.
The purpose of outpatient consent to treat is to ensure that healthcare providers have permission to provide treatment to patients on an outpatient basis.
Information such as patient's name, date of birth, medical history, treatment plan, and consent signature must be reported on outpatient consent to treat.
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