Consent Form
Please fill out the form below. If you prefer to print, fill out, and bring to your appointment, please download the PDF version.
HAVE READ THE FOLLOWING INFORMATION AND UNDERSTAND:
Anyone under age of 18 must be accompanied by a parent or a guardian
Tests are being performed at your request
Medical Specialists, PA will NOT submit these tests for insurance reimbursement. Upfront payment is required.
Results will not be forwarded or faxed to your physician. They will be directly forwarded to you via the manner you choose. You may share your results as desired.
I understand that it is my responsibility to send or share this information with my personal physician. Medical Specialists, PA is not proposing diagnosis or recommending medical treatment, but is merely acting as a resource to provide this additional, medical information. I understand that should I become ill, have any complaints, or have any questions regarding my health; it is my responsibility to contact my physician.
I am releasing all agents, employees, and volunteer personnel involved in this health screening from any and all liability for the results of the testing/screening or any treatment I may receive from a physician of my choice based upon the information provided by this program.
Abnormal results may be reviewed by a clinician. A letter of explanation will be included if necessary.
Critical results: If your results are critical, we will attempt to notify you as soon as possible using the telephone number that you provided. You should notify your provider as soon as possible to schedule an appointment. If you do not have a provider, you may contact Medical Specialists, PA providers @ 952 225-5400 to schedule consultation appointment.
