1. GENERAL CONSENT FOR TREATMENT AND TEST: I consent to treatment by Morgan P. Lorio, M.D., F.A.C.S. or John Testerman, M.D. and staff for my illness and/or health evaluations, including but not limited to x-rays, blood tests, laboratory procedures, medications and minor procedures. I acknowledge and agree that guarantees have been made to me as to the results or outcome of my medical care. I understand that state law requires physicians to report certain communicable diseases to the health department.
2. RELEASE FROM LIABILITY FOR LEAVING AGAINST MEDICAL ADVISE: I agree that if I leave a physician's office against the advice of my physician Morgan P. Lorio, M.D.,F.A.C.S., or John Testerman, M.D., the personnel, and my physician(s) are released from responsibility or liability for any injuries or damages which may result from my leaving against medical advice.
3. AUTHORIZATION TO RELEASE MEDICAL INFORMATION: I authorize Morgan Lorio, M.D., F.A.C.S. or John Testerman, M.D. and any physician(s) involved in my care to disclose and release my medical information (which may include alcohol/drug abuse, psychiatric, sickle cell anemia, AIDS and HIV test results) to each other and to any person or organization, which is or may be liable/responsible for payment of my bill, including medicare intermediaries and fiscal agents.
4. ASSIGNMENT OF INSURANCE BENEFITS/PROMISE TO PAY: For and in cosideration on services rendered and to be rendered by Morgan P. Lorio, M.D., F.A.C.S. or John Testerman, M.D., I hereby guarantee payment for all charges incurred for the account of the above named patient. I understand and agree that payment for such services shall be due at the time of service. I authorize and direct any person, firm or corporation including but not limited to insurance companies or attorneys representing the patient, or any other party for such services to assign proceeds of any payment for services rendered to said patient directly to Morgan P. Lorio, M.D., F.A.C.S. or John Testerman, M.D. Accepting assignment of said benefits, the provider does not relinquish the right to collect any balance not paid by any third party. I further agree that if such indebtness is placed in the hands of a collector or attorney for collection, I will pay reasonable collection fees and attorney fees, interests, court costs and other collection expenses.

I HAVE READ AND UNDERSTAND THIS DOCUMENT IN ITS ENTIRELY AND AGREE TO ITS TERMS.

Patient/Authorized Party: _________________________________________________________________________

Relationship: ______________________________________ Date: _____________________________

Witness: _________________________________________________________________