Consent Form

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Patient's Consents and Disclosures

* Indicates required field

Name of Patient *

The patient authorizes the Genesee County Free Medical Clinic to examine, perform diagnostic tests, administer medication as necessary, and the procedure written below.

Choose One *

Yes No

To the best of his/her knowledge, patient is not allergic to any medications other than those listed below: *

The patient consents to receiving services at the Genesee County Free Medical Clinic, which may include assessment, routine diagnostic procedures, medications, and such medical treatment as the attending Physician/Nurse Practitioner/Physician’s Assistant considers necessary for the patient’s care. Patient understands that the practice of medicine is not an exact science and he/she acknowledges that no guarantees have been made with regard to the result of examination or treatment at this clinic.

Patient understands that services received at the Genesee County Free Medical Clinic are being provided by health care practitioners and lay volunteers who are not receiving compensation. Patient further understands, as provided by Michigan law (MCL 333.16277), that these volunteers are not liable for civil damages as a result of acts or omissions which may occur in providing services to patient, except acts or omissions amounting to gross negligence or willful and wanton misconduct.

In connection with the treatment of our patients, it may be necessary to send them to a clinical laboratory or submit patient specimens to another laboratory, or refer a patient to another physician or medical facility for follow-up or continuing treatment.

Patient understands that he/she is responsible for their own valuables while at the Genesee County Free Medical Clinic and that the Clinic is not responsible for loss of or damage to any valuables.

My signature below constitutes my acknowledgement that I have understood this request and that I understand its contents.

Date *

Patient's Signature *

Physician Signature *

THE GENESEE COUNTY FREE MEDICAL CLINIC WILL NOT EXPECT YOU TO SIGN SUCH A FORM EVERY TIME YOU ARE SEEN BY A PHYSICIAN. PLEASE LET US KNOW IF YOUR WISHES CHANGE AT ANY TIME, WITH RESPECT TO THE USE OF THE PHYSICIAN, CLINICAL LABORATORY, OR OTHER MEDICAL FACILITY.

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Patient's Consents and Disclosures

PROVIDING HEALTHCARE TO THE UNDER SERVED​

PROVIDING HEALTHCARE TO THE UNDER SERVED