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I acknowledge full financial responsibility for any services rendered and I understand that the payment of charges incurred in this office are due at the time of service. I also understand that the charges not covered by insurance remain my responsibility and assign insurance benefits to this office. In the event my account is turned over to a collection agency, I agree to pay all costs of collection fees and/or attorney's fees and all court costs if any. I agree to be contacted at any telephone number or email address associated with my account. This includes cellular telephone numbers or other wireless devices.

I understand this could result in a charge from my phone or device carrier to me for talk time, SMS messaging/texts or data usage for emails or voice mails. I also understand methods of contact may include pre-recorded /artificial voice messages and/or the use of automatic dialing devices as applicable.

I have reviewed the Notice of Privacy Practices as provided at registration and understand that I may request a copy of the policy at any time. This also needs to be on that form with its own signature.

By signing below, I confirm that the information provided is accurate to the best of my knowledge. I understand that it is my responsibility to inform L&K Nursing and Family Practice of any changes to my information.

The undersigned I, the undersigned, hereby authorize and consent to the provision of medical care and treatment by the healthcare professionals employed or associated with L&K Nursing and Family Practice. This includes, but is not limited to, routine diagnostic procedures, medical examinations, laboratory testing, and treatment as deemed necessary by the attending physician or healthcare provider.

I understand that:

1. Nature of Treatment: The healthcare professionals at L&K Nursing and Family Practice may perform medical services related to my health condition, including physical examinations, diagnostic testing, and procedures as necessary.
2. Risks and Benefits:I acknowledge that the healthcare professionals will discuss the potential risks, benefits, and alternatives of any treatment recommended. I understand that no guarantees have been made regarding the results of any treatments or procedures.
3. Confidentiality: I understand that my medical records will be kept confidential and will not be released to any third party without my explicit consent, except as required by law.
4. Right to Refuse: I understand that I have the right to refuse or withdraw consent for any procedure or treatment at any time, even after it has begun, without affecting my right to future care or treatment
5. Financial Responsibility: I agree to be financially responsible for all charges related to my care and treatment, including but not limited to copays, deductibles, and any other costs not covered by my insurance. I understand that payment is due at the time of service unless other arrangements are made.
6. Emergency Care: In the event of an emergency, I authorize the staff at L&K Nursing and Family Practice to provide necessary emergency care until I can be transferred to a hospital or other appropriate facility if necessary.
7. Authorization for Communication: I authorize L&K Nursing and Family Practice to communicate with me through my provided contact details for appointments, test results, and other important medical information.
8. I acknowledge that I have been provided with an opportunity to ask questions about my care and treatment. I have had the risks and benefits of the proposed treatment explained to me, and I understand my rights and responsibilities as a patient.

By signing below, I confirm that I am voluntarily consenting to the treatment as described above.