Patient Intake Form

CONSENT FOR TREATMENT & FINANCIAL RESPONSIBILITY

Sawyer Medical PLLC

Direct Pay Medical Practice

Consent for Evaluation and Treatment

I voluntarily consent to receive medical evaluation, diagnosis, treatment, procedures, and healthcare services from Sawyer Medical PLLC, including care provided by physicians, physician assistants, nurse practitioners, nurses, medical assistants, and other authorized personnel acting within their scope of practice.

I understand that my care may include, when medically appropriate:

• Medical evaluations and consultations

• Telemedicine services

• Office visits and mobile medical visits

• Mobile IV hydration and IV infusion therapy

• Intramuscular and subcutaneous injections

• Blood draws and laboratory specimen collection

• Point-of-care testing

• Wound care and minor office procedures

• Administration of medications, vitamins, fluids, and other medically appropriate treatments

I understand that:

• I have the right to ask questions regarding my care and treatment.

• I may refuse any recommended treatment, procedure, medication, or diagnostic testing.

• Certain treatments and procedures carry inherent risks, including but not limited to pain, bleeding, bruising, infection, allergic reactions, medication side effects, IV infiltration or extravasation, nerve injury, phlebitis, vasovagal reactions, and, in rare circumstances, serious complications.

• Specific procedures may require additional informed consent before they are performed.

• No guarantees or assurances have been made regarding the outcome or results of any evaluation, treatment, medication, infusion, injection, or procedure.

  
  

Direct Pay / Self-Pay Acknowledgment

I understand that:

• Sawyer Medical PLLC operates as a direct-pay / fee-for-service medical practice.

• Payment is due at the time services are rendered unless otherwise agreed upon.

• Sawyer Medical PLLC may not bill insurance, Medicare, or Medicaid for services provided.

• I am financially responsible for all charges associated with my care.

I acknowledge that I may independently submit receipts or superbills to my insurance carrier if applicable, but reimbursement is not guaranteed.

Telecommunication Consent

I authorize Sawyer Medical PLLC to contact me regarding appointments, billing, follow-up care, and treatment recommendations by phone call, voicemail, email, or text message using the contact information I provide.

Patient Acknowledgment

By signing below, I acknowledge that:

• I have read and understood this form.

• I consent to treatment.

• I accept financial responsibility for services rendered.

HIPAA NOTICE OF PRIVACY PRACTICES & ACKNOWLEDGMENT

Sawyer Medical PLLC

Notice of Privacy Practices

This notice describes how your medical information may be used and disclosed and how you can access this information.

Sawyer Medical PLLC is committed to protecting the privacy and confidentiality of your protected health information (“PHI”) in accordance with applicable federal and Michigan law.

Uses and Disclosures of Medical Information

Your health information may be used for:

• Treatment

• Payment

• Healthcare operations

• Appointment reminders

• Coordination of care

• Legally required reporting obligations

We may disclose information when required by law, public health reporting requirements, court order, or medical emergency.

Your Rights

You have the right to:

• Request access to your medical records

• Request corrections to your records

• Request restrictions on certain disclosures

• Request confidential communications

• Obtain a copy of this privacy notice

• File a complaint regarding privacy concerns

Electronic Communication Acknowledgment

I understand that:

• Email and text communication may not always be fully secure.

• I may receive appointment reminders, follow-up communication, or administrative notifications electronically unless I opt out.

Acknowledgment

By signing below, I acknowledge that:

• I received or had access to the Notice of Privacy Practices.

• I understand my privacy rights.

TELEHEALTH INFORMED CONSENT

Sawyer Medical PLLC

Telehealth Consent and Acknowledgment

I understand that Sawyer Medical PLLC may provide medical services using telehealth technology, including video visits, telephone consultations, secure messaging, or other electronic communication methods.

Nature of Telehealth

I understand that:

• Telehealth involves communication using electronic technology rather than an in-person visit.

• My healthcare provider may review medical history, symptoms, images, recordings, or other health information remotely.

• Telehealth services may have limitations compared to in-person examinations.

Potential Risks

I understand potential risks of telehealth may include:

• Technical difficulties or interruptions

• Reduced ability to perform a complete physical examination

• Possible delays in evaluation or treatment

• Privacy or security risks despite reasonable safeguards

I understand that no electronic system can guarantee complete confidentiality.

Alternatives

I understand that:

• I may decline telehealth services at any time.

• I may request an in-person evaluation when available or appropriate.

• My provider may recommend in-person evaluation, urgent care, emergency department evaluation, or referral if medically necessary.

Emergency Situations

I understand that telehealth is not appropriate for all medical conditions or emergencies.

If I am experiencing a medical emergency, I should call 911 or go to the nearest emergency department immediately.

Treatment Decisions

I understand that:

• Testing, referrals, and treatment recommendations are made at the medical discretion of the provider.

• Certain treatments may not be appropriate through telehealth.

• A telehealth visit does not guarantee a diagnosis, work note, or treatment plan.

Consent to Telehealth Services

By signing below, I acknowledge that:

• I have read and understand this Telehealth Consent Form.

• I have had the opportunity to ask questions.

• I voluntarily consent to receive telehealth services from Sawyer Medical PLLC.