Scribd Logo
Upload

Welcome to Scribd!

  • 11 views

    Patient's Record - Agreement For Medical Home Visits

    Uploaded by

    Maria Perez
    This document summarizes an agreement for home medical visits. A patient consents to receiving medical services from Dr. [name] at their home. The patient provides their personal details including name, age, marital status, address, phone numbers, and social security number. They also list their primary physician's name, address, and contact information. The document is dated and signed by the patient, a witness, and the patient's tutor or representative.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd

    Patient's Record - Agreement For Medical Home Visits

    Uploaded by

    Maria Perez
    11 views1 page
    This document summarizes an agreement for home medical visits. A patient consents to receiving medical services from Dr. [name] at their home. The patient provides their personal details including name, age, marital status, address, phone numbers, and social security number. They also list their primary physician's name, address, and contact information. The document is dated and signed by the patient, a witness, and the patient's tutor or representative.

    Original Title

    Patient's Record - Agreement for Medical Home Visits

    Copyright

    © Attribution Non-Commercial (BY-NC)

    Available Formats

    DOC, PDF, TXT or read online from Scribd

    Did you find this document useful?

    Is this content inappropriate?

    This document summarizes an agreement for home medical visits. A patient consents to receiving medical services from Dr. [name] at their home. The patient provides their personal details including name, age, marital status, address, phone numbers, and social security number. They also list their primary physician's name, address, and contact information. The document is dated and signed by the patient, a witness, and the patient's tutor or representative.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    11 views1 page

    Patient's Record - Agreement For Medical Home Visits

    Uploaded by

    Maria Perez
    This document summarizes an agreement for home medical visits. A patient consents to receiving medical services from Dr. [name] at their home. The patient provides their personal details including name, age, marital status, address, phone numbers, and social security number. They also list their primary physician's name, address, and contact information. The document is dated and signed by the patient, a witness, and the patient's tutor or representative.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as DOC, PDF, TXT or read online from Scribd
    Download as doc, pdf, or txt
    of 1

    Agreement and Consent for Medical

    Home Visits

    I, ___________________________________________, _________years of age, civil status _____________


    residing in the town of ___________________ at the following address _____________________________,
    with telephone numbers __________________, and with social security number ________________________.
    Certify that my primary physician is:
    Name: ____________________________________________
    Address: __________________________________________
    Telephones: _______________________________________
    And that I voluntary and willingly requested the medical services of Dr. ______________________________
    in the character of physician to visit my home.
    Today ___________ of ___________________ 200___ in _____________________________, USA.
    (day)

    (month)

    ________________________________________
    Patients Signature
    ________________________________________
    Witness
    ________________________________________
    Tutor or Representative

    (year)

    (town)

    You might also like