This consent applies to “you” the patient, either yourself or the patient for whom you are the parent or legally authorized representative. Medical care is a patient care service in response to a wide range of medical care needs of patients of allages regardless ofgender, color, race, creed, national origin or disability.The purpose of medical care is:

• To treat disease, injury and disability by examination, testing and use of procedures as needed, in the aid of diagnosis or treatment.
• To obtain information needed in diagnosing and examining patients.
• To prevent or minimize residual physical and mental disability.
• To aid patients in achieving their maximum potential within their capabilities.
• To accelerate convalescence and reduce the length of the functional recovery.

You acknowledge that your medical care and treatment may be provided by a Medical Doctor, Mid-Level Practitioner, such as a Nurse Practitioner, a Physician’s Assistant or Health Professional Student under direct supervision of a Doctor; all referred to as a “provider” in this document. You are also aware that BHS Health Center Network does not provide emergency nor in-patient hospital services, although you can be referred to other providers of these services during regular clinic hours.

All procedures will be thoroughly explained to you before you are asked to perform them. You are expected to cooperate fully with the examination and stop any test or procedure before experiencing any increase in your current level of pain or discomfort. There are certain inherent risks with medical care; if you have any concerns about your proposed treatment as described by your provider please let them know prior to the examination or procedure. The provider will take every precaution to ensure that you are protected from any potentially hazardous situation. You will never be forced to perform any procedure that you do not wish to perform. Based on the above information, you agree to cooperate fully and to participate in all medical care procedures and to comply with the plan of care as it is established. You hereby request and consent to diagnostic procedures, laboratory, and medical treatment by the professional staff of BHS Health Center Network.

If you are requesting HIV/STD services, you give permission to the staff of BHS Health Center Network to draw your blood or collect a urine sample. You understand that you have the option to be tested for Syphilis, Chlamydia, Trichomonas, Gonorrhea, Hepatitis B, Hepatitis C and Herpes. You have been informed of the tests that you have elected to take, and you are aware that if you test positive for any of these tests, yourresults and any contact information will be provided to the Los Angeles or Orange County Department of Health Services Public Health Program, the Office of Health Programs and Epidemiology and the Acute Communicable Disease Control Unit, in accordance with California code of regulation, title17.

You acknowledge that BHS Health Center Network is an integrated care center, and grant access to your treatment records, diagnosis information, attendance or billing records, and other client information to other physicians, primary care providers and other staff involved in providing your services. You further authorize BHS Health Center Network to release medical/social information to persons or agencies directly concerned with public health or community welfare and to private individuals professionally engaged in carrying out a treatment plan for me.

You further acknowledge that you are financially responsible and agree to pay for any services that are not covered by your insurance, and to pay in full if you are not insured. 

You have received, read, and agreed to the attached terms and conditions of the “Registration Packet (04/2019)” and acknowledge that you have filled out the included information to the best of your abilities. You acknowledge that you have completely read, fully understand, and voluntarily agree to and accept this form. You have had the opportunity to discuss it, and your questions have been answered to your complete satisfaction.