1A – F1 – Consent to Treat

New Patient Registration

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Last Name

DOB

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Emergency Contact First Name

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Relationship to Patient

Emergency Contact Phone

Consent for Treatment

I hereby voluntarily authorize the physicians, nurses, and healthcare providers at Vertex Spine to perform reasonable and necessary medical examinations, tests, and treatment for the condition that brought me to seek care. I understand that if additional testing, invasive procedures, or surgical interventions are recommended, I will be provided with further explanation and asked to sign specific consent forms prior to those procedures. By selecting "I Agree" below, you acknowledge and agree that you are signing this Consent for Treatment electronically. You agree that your electronic selection is the legal equivalent of your manual/physical signature on this document, meeting all criteria under the Federal ESIGN Act and state law. You consent to be legally bound by this agreement's terms and conditions.

Authorized Representative (If other than the Patient)

Relationship to Patient

Electronic Signature Status

I Agree to the Electronic Signature Terms

Today's Date