Consent for Medication Administration
- I hereby authorize employees and agents of Urgent Care for Kids/Virtual Care for Families, including providers and other staff members to render medical evaluation and treatment to the patient listed on this form.
- I understand that our services are or may be provided through telemedicine and/or telehealth, through a combination of audio, visual and store and forward technology and are not appropriate for all medical issues and should not be used in emergency situations.
- I understand that there are potential risks associated with the use of telemedicine. These risks include, but may not be limited to, delays in medical evaluation and treatment due to limitations, deficiencies and/or failures of the technology. Additionally, in rare instances, security protocols could fail, causing a breach of privacy of personal medical information.
- I agree by accepting the services that the patient listed on this form is entering into a patient-provider relationship with the healthcare provider(s) that Urgent Care for Kids/Virtual Care for Families assigns to the patient.
- I understand that the services provided by Urgent Care for Kids/Virtual Care for Families do not replace an existing primary care physician relationship and, in certain instances, will require follow-up care with a local healthcare provider.
- I understand that the testing may involve the collection of bodily fluids or tissue (each a “Sample”), in accordance with standard testing procedures.
- I understand that while the tests performed on the patient’s Samples are approved by regulatory agencies and designed to detect the presence or absence of a specific disease or infection, they are not perfect or absolute. There is a statistical possibility that a test may yield a false positive or a false negative test result, which could result in an inadvertent misdiagnosis or delay in treatment.
- I hereby authorize our health staff to carry out orders and treatment plans as directed by Urgent Care for Kids/Virtual Care for Families providers to the patient listed on this form.
- I understand that by not signing this consent, this patient will not be provided with medical care by Urgent Care for Kids/Virtual Care for Families.
Consent for Medication Administration
- I hereby authorize our health staff to administer over-the-counter and prescription medication at the direction of a physician to the patient listed on this form in connection with orders and treatment plans directed by Urgent Care for Kids/Virtual Care for Families.
- I acknowledge that I have read the medication administration information earlier in this registration form.
- I agree to review and will provide any special instructions for the administration of the medication of the patient listed on this form and share that information with the patient’s school health staff.
- The duration of this consent lasts the discontinuation of active treatment under the patient-provider relationship.
By signing below, I acknowledge that I have been provided a read and understood the document in its entirety, including the below.
Notice of Privacy Practices
Preferred Method of Communication
Additional HIPAA Contacts
Financial Responsibility
Consent to Treat
Consent for Health Staff to Authorize Treatment
Consent for Medication Administration
This consent/authorization may be withdrawn in writing at any time.