Style 3 Demo

Consent for Treatment

Consent to examination and routine care.

Consent to examination and routine care

I ask Style 3 Demo and its clinicians to examine me and to provide the routine care, tests and treatment they recommend and I agree to.

Before a specific procedure, my clinician will explain what it involves, its expected benefits, its risks and the alternatives, including no treatment, and I can ask questions. A procedure that needs its own consent will be discussed and consented to separately.

I can ask questions, and refuse or stop care, at any time. No one has promised me a particular result.

Patient Name *

Email *

Date of Birth *

Who is signing this form? *

Patient (myself)

Parent or legal guardian

Other legal representative

Your full name *

Your authority to sign for the patient (for example, parent, court-appointed guardian or health care power of attorney) *

I have read this form and I agree to it. *

By signing below, you confirm the information you gave is accurate to the best of your knowledge and you agree to sign this form electronically. Your electronic signature has the same effect as a handwritten one. You can ask Style 3 Demo for a paper copy of this form at any time.

Date *

Signature *

Your information is encrypted and transmitted securely under HIPAA.

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