Due to COVID-19 the fees for our services have increased.

Vail, Colorado

970-763-7540

970-763-7540

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    • Home
    • Services
    • Fees
    • Appointments and Hours
    • Pediatric Telemedicine
    • Menu
      • FAQs
      • Contact Us
      • About Us
      • Testimonials and Press
      • Social Media
      • Pediatric Health Blog
  • Home
  • Services
  • Fees
  • Appointments and Hours
  • Pediatric Telemedicine
  • Menu

House Call Pediatric Urgent Care in Vail Valley

House Call Pediatric Urgent Care in Vail ValleyHouse Call Pediatric Urgent Care in Vail Valley

General Consent for Care and Treatment

 

General Consent for Care and Treatment Consent


TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended surgical, medical or diagnostic procedure to be used so that you may make the decision whether or not to undergo any suggested treatment or procedure after knowing the risks and hazards involved. At this point in your care, no specific treatment plan has been recommended. This consent form is simply an effort to obtain your permission to perform the evaluation necessary to identify the appropriate treatment and/or procedure for any identified condition(s). 


This consent provides Pediatrician Next Door, LLC and Gregory Miranda, MD with your permission to perform reasonable and necessary medical examinations, testing and treatment. By signing below, you are indicating that you intend that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended. The consent will remain fully effective until it is revoked in writing. You have the right at any time to discontinue services. 

You have the right to discuss the treatment plan with your physician about the purpose, potential risks and benefits of any test ordered for you. If you have any concerns regarding any test or treatment recommend by your health care provider, we encourage you to ask questions. 

I voluntarily request Pediatrician Next Door, LLC, Gregory Miranda, MD and other health care providers or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing and treatment for the condition which has brought me to seek care for my child__________________________________________ at this practice.                                                                                     Name of Patient


I understand that if additional testing, invasive or interventional procedures are recommended, I will be asked to read and sign additional consent forms prior to the test(s) or procedure(s).

I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.

__________________________________________                 ____________________________  

Signature of Parent or Legal Guardian                 Date

_________________________________________                  ______________________________

Printed Name of Parent or Legal Guardian      Relationship to Patient 

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  • *Pediatrician Next Door, the Two Houses logo, and "Your Pediatrician Next Door" are Trademarks of Pediatrician Next Door, LLC.
  • Dr. Miranda photo credit: Jen Winkeller, https://www.facebook.com/jenwinkellerphotography/

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  • Home
  • Services
  • Fees
  • Appointments and Hours
  • Pediatric Telemedicine
  • FAQs
  • Contact Us
  • About Us
  • Testimonials and Press
  • Social Media
  • Pediatric Health Blog

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Closed Until Further Notice

Dr. Miranda is currently unavailable for House Calls and Telemedicine. Please contact Colorado Mountain Medical (970-926-6340) or Avon Urgent Care (970-949-6100) for urgent care or visit your nearest ER for emergencies.