California law requires that we obtain your informed consent for a medical treatment. In keeping with state law, you are being asked to sign a confirmation that we have discussed the nature of your condition, the contemplated procedure, the general nature of the proposed treatment, the prospects for success and reasonable therapeutic alternatives to the treatment. We wish to inform you as completely as possible. You are also being asked to sign a confirmation that you have been given the opportunity to ask whatever questions you had and that your questions have been answered in a satisfactory manner.
I hereby authorize and direct Morton W. Barke, M.D, Inc. and associates or assistants to examine me. The treatment has been explained to me. Alternative methods have also been explained to me, as have the advantages and disadvantages. I am advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the success or other result of treatment
I attest that the information on this form is correct and any medical history presented or discussed with the doctor is also factual and complete to the best of my knowledge. Solely for verification purposes, I authorize Morton W. Barke, M.D., Inc. and its’ staff to converse about my medical condition with physicians that I have previously been treated by
The doctor that examines you may be an independent contractor; therefore, Morton W. Barke, M.D., Inc. is not liable for any action by the independent contractor. Furthermore, the undersigned, my heirs, assigns, or anyone acting on my behalf, hold the physician and his/her principals, agents, employees, free of and harmless from any liability. Following the exam with the physician, I understand that there is no refund of the fee for the exam or treatment.
I am aware of the Privacy Practices Notice posted on the premises which presents the information that federal law requires us to give to our patients regarding their privacy rights and our privacy practices.
Service Animal Patients: I give my consent that my Service Animal Letter may be verified with housing landlords, airlines, and law enforcement. I also have read and understood the Animal Behavior Agreement.
Agreement to Arbitrate: It is understood that any claim of malpractice, including any claim that health care services were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered or omitted, will be determined by submission to binding arbitration, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. The patient has the right to seek legal counsel concerning this agreement, and has the right to rescind this agreement by written notice to the physician within ninety days after the agreement has been signed and executed by both parties. Both parties to this agreement, by entering into it, have agreed to the use of binding arbitration in lieu of having any such dispute decided in a court of law before a jury.