Consent Agreement

General Consent for Second Opinion:

TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended.  This is a Second Opinion ONLY and is NOT intended as any form of Treatment in any way.  This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate Second Opinion in this case.

 This consent provides us with your permission to perform reasonable and necessary medical evaluation to provide appropriate Second Opinion. By signing below, you are indicating that (1) you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended; and (2) you consent to treatment/evaluation at this office or any other satellite office under common ownership. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services.

 You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any Second Opinion provided.  In fact, we at Second Opinion recommend that you speak to your PCP, primary treating provider for pathology at hand, and any other professional to determine plan of care.  If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions.

I voluntarily request a physician, and/or mid level provider (Nurse Practitioner, Physician Assistant, or Clinical Nurse Specialist), and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment/evaluation for the condition which has brought me to seek care at this practice. I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s). Risks and benefits of using Second Opinion are discussed and understood.  No fault shall be placed on the provider(s) of Second Opinion in providing a complete evaluation of information provided along with presentation of their viewpoints in a cohesive manner with hopes of helping the patient decide with their medical professional the next steps in treatment. Any problem(s) that may occur before or after treatment relatable to the pathology discussed are not the fault of second opinion and this is understood by the patient.

It is noted that no recording (Audio/video) of discussions held by phone or in person will be allowed and ample time will be permitted to discuss topics so that they are clearly able to be understood and written down.

Finally, it is noted that the payments made for Second Opinion are made for evaluations by qualified professionals in their particular fields and are non-refundable. 

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.