Disclaimer
BuiltSIGN templates are provided for convenience, are not legal advice, and should be reviewed by a licensed attorney in the relevant state.
Healthcare and consent
Patient Intake Consent
Consent to an evaluation and to the clinic contacting the patient. It is not a HIPAA authorization.
The legal text of this template is still in English. It needs a human translation by someone qualified in that language and jurisdiction. BuiltSIGN does not machine-translate template bodies.
Preview
Needs legal review
State informed-consent rules differ by procedure. This form is a general intake, not a procedure-specific consent.
Consent
The patient consents to an evaluation by {{provider}} for {{reason}} and to routine questions needed for that evaluation. The patient may stop the evaluation. This form does not authorize surgery, and it is not an authorization to release records to a third party.
Governing law and venue
This agreement is governed by the laws of {{governingLawState}}, without applying conflict-of-law rules that would select another state's law. Venue lies in the state or federal courts located in that state unless a statute that applies to this agreement requires a different foru…
Questions
What is the Patient Intake Consent template?
Consent to an evaluation and to the clinic contacting the patient. It is not a HIPAA authorization. It is a Healthcare and consent template in the BuiltSIGN gallery.
Who signs this template?
The template includes fields for Clinic, Patient.
Is this legal advice?
BuiltSIGN templates are provided for convenience, are not legal advice, and should be reviewed by a licensed attorney in the relevant state.
Is the template text translated?
No. The legal text stays in English until a person qualified in that language and jurisdiction translates it. BuiltSIGN does not machine-translate template bodies.
BuiltSIGN templates are provided for convenience, are not legal advice, and should be reviewed by a licensed attorney in the relevant state.