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Patient Forms

Welcome to the Patient Forms page of Packer Medical Center.

There are two required forms that must be completed electronically as part of your patient intake and before your appointment is confirmed:

1. General Consent to Treat FormSignature and Agreement

By entering your full name in the contact form, you acknowledge that your name serves as a digital signature and holds the same legal value as a handwritten signature.

This confirms that all the information you have provided is accurate and that you agree to the terms outlined in our Patient Policies.

Your name will be used to process your records, consent, and any necessary medical documentation.

1. General Consent to Treat Form

2. Financial Consent Form

Please complete and electronically submit both forms. The General Consent to Treat Form is the first form and appears on this page to the right.

After completing the General Consent to Treat Form, please follow the instructions on this page to access and complete the Financial Consent Form.

Completing both forms in advance helps us prepare for your visit and streamline your appointment and check-in process.

Signature and Agreement

By entering your full name in the contact form, you acknowledge that your name serves as a digital signature and holds the same legal value as a handwritten signature. This confirms that all the information you have provided is accurate, and you agree to the terms outlined in our Patient Policies. Your name will be used to process your records, consent, and any necessary medical documentation.

Financial Consent Form

The Financial Consent Form is the second required form. After completing your General Consent to Treat Form, please click the button below to complete and electronically submit your Financial Consent Form.

COMPLETE FINANCIAL CONSENT FORM

Submit Your Forms

Please complete both required forms online and submit each form electronically by clicking the SUBMIT button at the end of the form.

Both the General Consent to Treat Form and Financial Consent Form must be completed and electronically submitted as part of your patient intake before your appointment is confirmed.

Privacy Notice

All patient information is kept confidential and is securely stored according to HIPAA guidelines. By submitting this form, you consent to the use of your data for medical purposes only.

Please click the button below to review our HIPAA Privacy Policy.

HIPAA PRIVACY POLICY

Consent to Treat Form

Please complete your information and review the consents below. Only one signature and date are needed on this form. Fields marked * are required.

Full Name

Address

Phone

E-mail

Date of Birth

Emergency Contact Name

Emergency Contact Phone

Preferred Pharmacy

Insurance Provider

Insurance Member ID

Current Primary Doctor Full Name

Current Primary Doctor Address

Current Primary Doctor Phone Number

Current Specialty Doctor Full Name

Current Specialty Doctor Address

Current Specialty Doctor Phone Number

Primary Medical Conditions

Current Medications

Allergies

Past Surgeries/Hospitalizations

Family Medical History

Consent for Treatment: I consent to medical evaluation and treatment by Packer Medical Center, including medically appropriate examination, diagnostic testing, treatment, prescriptions, and referrals. I may ask questions about my care and discuss treatment choices with my provider.

I agree

Telemedicine Consent: When medically appropriate, I consent to care through telemedicine. I understand its benefits and limitations, including technology failures, privacy risks, and the inability to perform a complete physical examination remotely. An in-person visit, testing, or other care may be needed. I may decline telemedicine and discuss alternatives. Telemedicine is not for emergencies; for a medical emergency, call 911.

I agree

Review of Medical and Medication Information: For my care, my provider may review available outside medical records, pharmacy and medication histories, health information exchange information, including CRISP, and prescription information, including the Maryland Prescription Drug Monitoring Program (PDMP), as permitted or required by law. Records may be obtained or shared for treatment and other legally permitted purposes. This form does not replace a separate authorization or specific consent when one is required by law.

I agree

Practice Communications and Secure Intake: I consent to appointment reminders and practice-related communications by telephone, email, or other electronic methods, subject to applicable law and my stated preferences. SMS/text messaging is a separate optional choice below. I agree to submit my government-issued photo identification and insurance card, if applicable, through the secure Tebra link provided during intake.

I agree

Financial Form: I understand that the separate Financial Consent Form addresses patient financial responsibility, insurance assignment of benefits, cancellation and no-show policies, and card-on-file authorization. I must complete that form separately. The Financial Consent Form is available on our Patient Financial Policy page.

I understand

Electronic Signature and Patient Certification: I consent to electronic records and signatures for this form. By typing my full legal name and submitting the form, I intend that entry to serve as my electronic signature to the extent permitted by law. I certify that my information is true, complete, and accurate to the best of my knowledge. I am the patient or a legally authorized representative with authority to provide these consents. My signature covers the treatment, telemedicine, medical-information review, communications and intake, financial-form acknowledgment, and electronic-signature statements above, together with the choices I select below.

I agree

HIPAA Privacy Acknowledgment: Please review our Notice of Privacy Practices and Privacy Policy. If you have not received the notice or would like a copy, please tell our office. Leaving this acknowledgment unchecked does not by itself prevent care.

I acknowledge that I received or was provided access to the Notice of Privacy Practices. This acknowledges receipt; it is not authorization for additional uses or disclosures of my information.

Optional SMS Consent

I agree to receive SMS/text messages from Packer Medical Center regarding services, scheduling, and account updates. Message frequency varies. Message and data rates may apply. Reply STOP to opt out or HELP for assistance. Consent is not a condition of purchase.

One Final Signature

I have read and agree to the consents and certification above, and I consent to use my electronic signature on this form.

Full Legal Name (Electronic Signature)

Date

Legally Authorized Representative

I am signing as the patient’s legally authorized representative.

Relationship to Patient (if signing as representative)

Authority to Sign (if signing as representative)

I agree to the Terms & Conditions and Privacy Policy

Submit