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tests or treatment(s). I authorize and consent to use of recordings, films, or other images of me (i.e., any photographic, vide o, electronic or audio media) for purposes of identification, diagnosis or treatment in connection with the care provided to me. 4. Agreements and Understandings: a.
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CONSENT FOR ADMISSION / TREATMENT
mychart.utsouthwestern.eduFORM # 80935 (06/07) (Rev. 07/08/2020) White - Health Information Management Yellow - Patient Location of treatment: cUT Southwestern University Hospital Outpatient c Surgery Center (clinic name) 1. APPLICATION FOR ADMISSION AND CONSENT FOR TREATMENT: I voluntarily consent to the procedures and services that may be performed for me on an …
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