GENERAL TREATMENT CONSENT FORM

• The validity of this consent is ongoing for the medical center unless otherwise stated.
• This consent is obtained upon registration and opening a new file at the center.

Consent for Medical Treatment

• To undergo, examination, routine investigation, blood tests, x-rays, and treatment which are considered necessary by the medical staff for diagnosis and treatment. I am aware of who will oversee my treatment, and I understand that I can get information about my condition at any time during my treatment by asking the treating physicians. I acknowledge that it is not possible to predict or guarantee any medical results.
• I know that the members of the treating medical team consist of the treating physicians and their representatives and the staff working in the medical center, including but not limited to professional medical staff, nursing staff, technicians, and other staff entrusted with working and supervising the provision of health care to patients.
Authorization for Release and Use of Medical Information
• I understand that my medical record may be utilized and authorize access to persons involved in my care.
• I authorized my doctors to take my medical history during the examination and perform interventions such as nail procedures, skin/wound debridement, sampling and blood investigations, and administering injections for treatment, anesthesia, and the like if deemed necessary for the treatment and management of my condition.
• I agree that [Khalid Mohammed Edrees Specialized Medical Center] can send copies of my medical records or any relevant information to my sources of payment, as well as the government agencies and legal authorities requiring my health information. It is in my understanding that my information will be sent as a pre-requisite in paying my medical bills and/or in case of investigations/legal actions.
• I approve the use of my medical data, information, and reports for the purposes of scientific research and studies, given that my identity and personal information will be kept confidential.
Consent to Take and Use Medical Photographs
• I authorize the medical team, to photograph my condition for the purposes of monitoring and assessing my prognosis and may be used as a medical reference and health teaching through various media platforms. In this regard, my attending physician has ownership of the photos taken, given that my identity and personal information will be kept confidential. I am fully aware that my case and images taken during the course of treatment may be used as a subject in the purpose of scientific studies and not as a subject for any medical procedure.
Patients’ Rights & Responsibilities
• I acknowledge that I have been informed on the patients’ rights and responsibilities.
Financial Responsibility
• I agreed to attend to my financial responsibilities, including but not limited to the payment of the amounts due to Dr. Khalid Edrees Specialized Medical Center when requested or due to the health services rendered to me.
• I authorize [Khalid Mohammed Edrees Specialized Medical Center] to disclose to my insurance company or any other parties that may be liable all or part of the charges, all or part of my medical records, if necessary to process payments the health care services provided.
• I understand that as a courtesy to me the center will fill an insurance claim with my insurance company but that I am financially responsible for all charges not covered by the insurance company or third-party payors as per the Saudi laws & regulations.
Release From Responsibility for Loss of Valuables
• Edrees medical center is not responsible for missing valuables, including money, jewelry, glasses, documents, and other personal items.
Release from [Refusal of Treatment/Medical advice] Responsibility
• If I should leave the medical center against medical advice or prior treatment is completed, I hereby relieve said physician and the medical center of all liability for my action.
Instructions & General Guidelines
• The service must be used within 30 days from the date of purchase.
• In the event of a refund request for the value of the service that was purchased through Tamara, the refund request will be accepted within 7 days from the date of purchase, and 10% of the value of the administrative fee will be deducted.
• I agree to abide by the center’s NO SMOKING Policy inside or around the center.
• I agree to refrain from sending messages from or using a mobile phone while in the areas with restricted mobile and wireless equipment use, and this is to prevent any interference with medical equipment in the center.
• I was advised of the center rules for infection diseases (i.e. Covid-19) and I and my family will be compliant with the rules. Violation may lead the medical center to take appropriate action.
• I know that assaulting a health practitioner, verbally or physically, is a crime punishable by law
• I acknowledge that I have been notified of the waiting period, which may be up to two hours.