1. I voluntarily consent to any and all health care treatment and diagnostic procedures provided by Shady Grove Internal Medicine and its associated physicians, clinicians, and other personnel. I am aware that the practice of medicine and other health care professions is not an exact science and I further state that I understand that no guarantee has been or can be made as to the results of the treatments or examinations at Shady Grover Internal Medicine.

2. I agree to be contacted via Phone, Email or SMS with information related to my visit, like a patient portal invitation, post-visit satisfaction survey, appointment or checkup reminders, health tips, or new services that relate to me or my family.

3. I consent to the use and disclosure of my/the patient’s protected health information for purposes of obtaining payment for services rendered to me/the patient, treatment, and health care operations consistent with the Shady Grove Internal Medicine Notice of Privacy Practices.

4. I authorize payment of medical benefits to Shady Grove Internal Medicine physicians or their designee for services rendered.

5. I give permission to obtain all my medication/prescription history when using an electronic system to process prescriptions for my medical treatment.