Consent to Treat Form

I have the legal right to give consent to the medical treatment of this patient. I voluntarily authorize and consent to medical care, treatment, and diagnostic tests that In & Out Pediatrics believe is necessary for this child. I understand by signing this form, I am giving permission to the Pediatric Nurse Practitioner and medical assistant to provide treatment to this patient. During the course of my care and treatment, I understand that various types, diagnostic, or treatment procedures may be necessary. These procedures are performed by the Pediatric Nurse Practitioner. While usually performed without incident, there are potential risk associated with each of these procedures. It is not possible to list every risk for every procedure and this form will therefore list the most common possible risks. It is important to note that a simple act as taking a commonly used medication can rarely cause severe reactions that could lead to organ failure or even death. If I have any questions or concerns regarding these procedures, I will ask the Pediatric Nurse Practitioner to provide me with additional information. These procedures include needle sticks such as shots or injections. Material risks include, but are not limited to infection, disfiguring scar, nerve damage with possible loss of limb function. Alternatives to needle sticks (if available) include oral, rectal, nasal, or topical medications (each of which may be less effective) or refusal of treatment. Physical tests, assessments, and treatments such as internal body examinations, wound cleaning and wound dressing. Material risks include allergic reaction and infection. Apart from using modified procedure and/or refusal of treatment, no practical alternative exists. Administration of medication whether orally, rectally, topically, or through the eye, ear, or nose. Material risks include, but are not limited to, allergic reaction, puncture, and perforation. Apart from varying the method of administration and/or refusal of treatment, no practical alternative exists. I understand that the practice of medicine is not an exact science and that no guarantee or assurances have been made to me concerning the outcome and/or result of any procedures. The health care professional participating in my care will rely on my documented medical history, as well as other information obtained from me, my family, or others having knowledge about me, in determining whether to perform or recommend the procedures, therefore, I agree to provide accurate and complete information about my medical history. I may be asked to sign additional required informed consent documents for specific procedures and tests. By signing this form, I consent to the healthcare professional performing procedures as they deem reasonably necessary or desirable in the exercise of their professional judgment, including those procedures that may be unforeseen and not known to be needed at the time this consent is obtained. I acknowledge that I have been informed, in general terms, of the nature and purpose, the material risks and the practical alternatives of the procedures. I understand that In & Out Pediatrics uses a Pediatric Nurse Practitioner who has been approved by the Georgia State Board of Medical Examiners. Your signature on this approval form conveys that you are in agreement with being treated by our Pediatric Nurse Practitioner who act under the supervision of a George Medical Board certified delegating physician.

Financial Policy Form

We strive to provide affordable, quality care. We accept cash and all major credit cards. Payment is due at the time of service. My signature on this form conveys that I acknowledge and agree to payment in full at the time of service.

  • $100 per house call
  • $60 Sports Physical
  • $25 for each additional test or procedure
  • $5 Medication Administration
  • $55 Telemedicine (virtual visit using your phone or computer)

Sports Physical Form

We perform sports physicals. However, we require any child with an extensive medical history to be seen by their primary care provider. Extensive medical history includes: Asthma, Anemia, Diabetes, Cancer, Seizures, Heart Murmur, Heart Infection, Kidney Disease, Kawasaki Disease, Hernias, Head Injury, Sickle Cell Anemia, Eating Disorder, Marfan Syndrome, Down Syndrome. I also have not had any recent issues with fainting, chest pain, shortness of breath, wheezing, broken bones, sprains, numbness, vision problems, hearing problems, possibility of pregnancy . None of my family members or relatives died of heart problems or had an unexpected or unexplained sudden death before age 50. I have read and acknowledge that none of the above information applies to me and I would like to have a Sports Physical performed by the Pediatric Nurse Practitioner.

Check In/Medical History Form

Some instances require a visit to the hospital or to your child’s doctor. You should not schedule a house call visit if your child is 3 months or less with a fever of 100.4 or greater, if your child has been poisoned, has a seizure, severe bleeding, right lower quadrant pain, head injury, broken bones, dehydration, severely burned, difficulty breathing, fainting, swallowed object, or with an extensive medical history.