When you receive this form受診するすべての新しい医療施設やクリニックで渡されます。一部の医療提供者は毎年更新します。未成年者または同意能力のない成人の代わりに署名する場合は、承認された代理人として署名します。
What to bring or have ready政府発行の身分証明書。未成年者または判断能力のない成人の代わりに署名する場合は、権限を証明する書類（出生証明書、法的後見命令書、または医療に関する永続的委任状など）をお持ちください。
患者または授権代理人 / Patient or Authorized Representative
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Patient full name
患者氏名
The legal name of the person receiving care, as it appears on their ID or insurance card. If the patient is a child or cannot speak for themselves, you will complete the rest of this section as the authorized representative.
The patient's date of birth, used to confirm identity and retrieve records. Write in MM/DD/YYYY format.
患者の生年月日。本人確認と記録の取得に使用します。MM/DD/YYYY形式で記入してください。
Authorized representative name (if signing for another person)
承認された代理人氏名（他の人の代わりに署名する場合）
Complete this field only if you are signing on behalf of the patient. Leave blank if the patient is signing for themselves. This applies to parents signing for a child, legal guardians, or adults holding a valid healthcare power of attorney.
For example: parent, legal guardian, spouse, adult child, or power of attorney holder. If you have a legal document establishing your role, note the document type here.
By initialing or checking this box you confirm that you have read, or had read to you, the consent statement. The statement typically says you allow the provider to conduct standard physical exams, draw blood for routine lab tests, take X-rays, and administer basic treatments necessary for your care. It does NOT authorize surgery, invasive procedures, or experimental treatments — those require a separate informed consent discussion and signature.
Sign in the space provided. If you cannot sign (for example, due to a physical limitation), ask a staff member about alternatives — some facilities allow a mark or a verbal consent noted by a witness.
A staff member or other authorized person may sign as witness to confirm that the consent was given voluntarily and that the signer appeared to understand the document. Not all facilities require a witness signature for routine consent forms.
Authorization for emergency care if unable to consent
同意できない場合の救急処置の承認
This clause typically states that if you become unable to consent during a visit — for example, due to loss of consciousness — the provider is authorized to take whatever life-saving actions are immediately necessary. This clause does not override a valid advance directive or Do Not Resuscitate (DNR) order.
Select yes if you have a signed advance directive, living will, or POLST (Physician Orders for Life-Sustaining Treatment) and provide a copy to the facility. These documents communicate your wishes about care if you cannot speak for yourself, and the care team is legally obligated to honor them.
Many general consent forms include a brief statement that you acknowledge responsibility for charges not covered by your insurance. This is not a detailed financial agreement — a separate billing form handles that. If you have questions about costs before treatment, ask the front desk or billing department before signing.
Confirmation that insurance information has been or will be provided
保険情報の提供済みまたは提供予定の確認
This statement confirms that you will share your insurance card and member ID with the provider so they can bill your plan directly. If you do not have insurance, you may note this here and ask about self-pay rates or financial assistance programs before your appointment.