Trinity Heritage Clinic - Patient Intake Form

I understand that my health condition may require diagnosis and treatment. I hereby voluntarily consent to such treatment, services, and procedures as ordered by my doctor, his consultants, associates and his assistants, or his designee. I also understand student nurses and others in professional training programs may be among the individuals who provide care to me.

I authorize Dr. Nwiloh and his assistants/designee to discuss my medical history, diagnosis, treatment, and prognosis as provided in the notice of privacy practices. I understand this may include information regarding testing, examination and treatment for HIV, AIDS related illness, mental health and drug, alcohol, or chemical abuse. I have the right to add anyone or any organization that I do not wish to have my medical information by requesting in writing at any time.

I understand there are times when the law allows Dr. Nwiloh and his assistants/designee to release information regardless of whether I give my consent as outlined in the notice of privacy practices. For example, Dr. Nwiloh and his assistants/designee may release information to doctors, nurses and other who provide me with health care or are prospective health care providers; to government agencies as authorized by law to insurance companies or others who are responsible for paying my medical bills; or to a court of law that issues a subpoena or court order. I understand this information may be released either orally or in document form.

I also understand and acknowledge that Texas law provides if any health care worker is exposed to my blood or other bodily fluid, Dr. Nwiloh and his assistants/designee may perform tests, with or without my consent, on my blood or other bodily fluid to determine the presence of any communicable disease, including but not limited to, Hepatitis, HIV/AIDS and Syphilis. I understand that such testing is necessary to protect those who will be caring for me while I am a patient of Dr. Nwiloh. I understand that the results of tests taken under these circumstances are confidential and do not become a part of my medical record.

I acknowledge that it may be difficult for the physician(s), his/her assistants, or his/her designee to personally communicate with the patient regarding laboratory/diagnostic test results, etc. It is the policy of Dr. Nwiloh’s Office to leave this information on the patient's telephone answering machine.

NO GUARANTEE: I acknowledge that the practice of medicine is not an exact science and that Dr. Nwiloh has made no guarantees or warranties to me as to the result of treatments or examination.

It is the policy of Dr. Nwiloh's Office not to release confidential medical information to patient’s family members. We cannot discuss your medical condition or release diagnostic test results to anyone without your consent. I hereby give consent that information regarding my medical condition, including laboratory and diagnostic test results can be given to: