BLYTHE FAMILY HEALTH CARE

Consent for Treatment

I, _________________________, hereby consent for treatment at this facility for either myself or my minor child (or another person for whom I have medical power of attorney) listed below. This consent will remain valid unless cancelled in writing. I understand that all treatments or even lack of treatment carries certain risks and benefits. I understand that Dr. Blythe will help me to understand the benefits and common risks of any recommended treatment. It is my responsibility to request further information if there is anyting about the risks and benefits that I do not understand.

I agree to read any written material provided by Dr. Blythe and/or the pharmacist regarding any medications that I may be prescribed. I also agree to be truthful about any medical conditions, risks, or exposures that I may have now or may have had in the past, and will notify Dr. Blythe promptly of any changes in my medical condition.

I understand that minor procedures involving injections, scraping, freezing, cutting, and sewing may sometimes lead to side effects such as pain, bruising, bleeding, scarring, or infection in spite of our best efforts to prevent those effects. Although these risks of any minor procedures in the office may be reviewed prior to such procedure, this constitutes my acknowledgement of the inherent risks of any such procedure and no further written consent will be obtained.

I understand that I have the option to communicate with Dr. Blythe's office via the internet. I understand that the office is using the most up-to-date methods of communications taking advantage of a secure server system to provide the maximum possible security of patient information. I consent to communicating with Dr. Blythe via this system if I provide an e-mail address.

Living Will or Advanced Directive?	 NO  YES (please provide us a copy
Other restrictions on care?	 NO  YES: _____________________________
Signature of Patient or Patient's Guardian	____________________________________________
Date:	____________________________________________
Patient's name, if different.*	____________________________________________

* In the case of a non-parent guardian or medical power of attorney, please provide us with copies of all relevant documents. Thank you.