When you receive this form在您就诊的每个新设施或诊所时。一些提供者每年更新一次。如果您代表未成年人或无法同意的成年人签名，您将作为授权代表签名。
What to bring or have ready您的政府颁发的身份证件。如果您代表未成年人或无行为能力的成年人签名，请携带您权限的证明文件——例如出生证明、法定监护令或医疗持久授权书。
患者或授权代理人 / Patient or Authorized Representative
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Patient full name
患者全名
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.
患者的出生日期，用于确认身份和检索记录。请使用月/日/年格式填写。
Authorized representative name (if signing for another person)
授权代理人姓名（如果代表他人签名）
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.
The date you sign the form. This confirms the consent was given before treatment began. Write in MM/DD/YYYY format.
您签署表格的日期。这确认同意在治疗开始之前给予。请使用月/日/年格式填写。
Witness signature
见证人签名
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
在无法同意时的紧急护理授权
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
确认保险信息已经或将要提供
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.