Appointment contract and treatment authorization

Appointment Contract and Treatment Authorization

Treatment Authorization

I hereby consent to the authorization of such medication and the performance of such treatment needed/necessary while a patient at Lake County Free Clinic.

I also consent to the release of such information regarding my case to any physician referrals deemed necessary of advisable while a patient at Lake County Free Clinic.

Patient Appointment Contract

LCFC requires that every patient annually reviews our policy about keeping and cancelling appointments. Your signature below indicates that you understand each line.

I will give at least 24 hours notice if I am unable to keep my scheduled appointment. Call 440-352-8686 to cancel an appointment. (You can also sign up for MyChart to send secure messages to LCFC electronically.)

If I do not provide 24 hours notice before cancelling my appointment, it will be considered a missed appointment (no-show appointment).

If I miss 2 appointments in 12 months I may not be able to reschedule for services at LCFC again for 6 months.

If I am not able ot be seen due to missed appointments, I will also be ineligible for prescription refills from LCFC.

If I miss 3 appointments in 12 months I may be permanently ineligible for prescription refills from LCFC.

It is my responsibility to keep my contact information current and I will update LCFC any time it changes.

I may be restricted from making appointments without being notified if I cannot be reached.

If I need an interpreter, it is my responsibility to have this arranged for my appointment. I understand my appointment may have to be rescheduled if no interpreter is present.

By signing this form, you:



Consent to the authorization of treatment and release of information as needed.

Understand and agree to the terms of the patient contract.