Patient Forms

I consent to treatment by Shore Health & Wellness Center's Providers and staff for my healthcare, including but not limited to exams, testing, medications, and minor procedures. I acknowledge and agree no guarantees have been made to me as the results or outcome of my care. I understand that State Law requires physicians to report certain communicable diseases to the Health Department.

If at any time I have questions about my examination, diagnosis, or treatment, I will not proceed until my questions have been answered to that I am fully informed. I understand that giving the providers and nurses all relevant information is important to my proper diagnosis and treatment. I understand complete compliance with my provider’s instructions is critical to the success of any treatment prescribed.

I authorize Shore Health & Wellness Center to release my health information to my health plan or to a health and wellness provider
approved by my health plan for purposes of advising me concerning appropriate measures to maintain or improve my health or anycondition reflected in my records. I authorize Shore Health & Wellness Center to release information to my designated insurance plan for the purpose of health plan administration, including receiving or making payment for services rendered on my behalf. I understand
a patient is responsible for all charges incurred, subject to contract and program rules, regardless of my insurance status. If it becomes necessary to send this account to collections, the patient will be responsible for all additional charges.