Vanguard University of Southern California Health Center
55 Fair Drive Costa Mesa, California 92626 (714)-619-6471
CONSENT FOR TREATMENT (Page 1 of 2)
This consent will be effective for 1 year after the date it is signed at VU Health Center of which I
am a patient.
Acknowledgement of Notice of Privacy Practices
The Notice of Privacy Practices is a complete description of my privacy rights as a patient of Vanguard
University Health Center. By signing below, I am stating I have received VU Health Center’s Notice of
Privacy Practices.
PATIENT________________________________________________ CAMPUS ID#: __________________
(OR AUTHORIZED REPRESENTATIVE)
Consent for Treatment/Care
I consent to medical examinations, treatments, testing, and care by VU Health Center in accordance with
their professional judgment. I understand that my treatment and care may include acute care services and
any necessary follow-up and a variety of other medical services depending on my condition, such as
laboratory testing. I can receive a list of services and care from my health care provider. I understand that
my care team at VU Health Center may include student assistants or other trainees. I am aware that the
practice of medicine (including minor surgical procedures) is not an exact science; treatments and testing
may involve unforeseen risks, including complications and no one has made any guarantees about the
results of my treatments, examinations, or procedures including positive outcomes or cure. All patients
have the right to be informed of such risks as well as alternative treatments or options of care. Except in
cases of emergency, treatments and testing will not be performed without the patient’s signed informed
consent. You have the right to consent to or refuse any proposed treatment or test.
I have accurately completed the Medical History intake information form, identified all my
medical/physical conditions, medications I am taking (including over-the-counter), and known allergies.
I understand that VU Health Center depends on information I have provided, and any discrepancies may
complicate my treatment, cause injury and/or reduce my chances of successful treatment outcome. If there
is any change in any of my medical history, I agree to provide VU Health Center with all updated
information.
I understand that the VU Health Center has limited clinic hours and is open and available only while
school is in session, and if there is an emergency while school is not in session, I will have to make my
own arrangements for receiving health care.
Consent for Use and Release of Information
The student /health care provider relationship is confidential and information will not be disclosed
without your written permission EXCEPT by court order, subpoena, or where reporting is required by law
including: 1) when the patient may harm himself/herself or others 2) when there is reasonable suspicion
of domestic violence including child abuse, spousal abuse, or abuse of the elderly.
I give permission to VU Health Center– including its supervising physicians, treating and referring
providers and other staff members – to release any information about me, my health, the health services
provided to me, or payment for my health services, that may be necessary: (1) for my treatment (to health
care providers or facilities that need the information for my continued care); 2)for the health care
operations of the VU Health Center or another health care provider that has had a relationship with the
Health Center (supervising physicians, quality assessment, training programs, and planning).
For more detailed information about the way my information may be used or released, I can read the VU
Health Center’s Notice of Privacy Practices.
General Consent For Treatment
Medical Records Form
Revised: August 2015
GENERAL CONSENT FOR TREATMENT (CONTINUED) – PAGE 2 OF 2
Financial Responsibility
I understand and agree that the VU health service charge of 35$ a semester is only for access to the VU
Health Center health care providers and does not include certain laboratory tests offered by the VU Health
Center which I may consent to purchasing at a minimal fee offered by VU Health Center. I understand
and agree that charges for medical and related professional services performed or by a physician and/or
hospital outside of VU Health Center will be billed separately. I also understand that an insurance
company may not pay the full amount of my charges, and I may be responsible (as a patient, spouse, or
the parent of a minor child) for the amount not paid. If I do not have health insurance or have not
provided current or accurate insurance information, I am responsible for payment of all charges.
Wireless Telephone Number/Email
VU Health Center staff and health care providers may contact me by telephone at any number and email
address contained in my VU Health Center records, including wireless telephone numbers and email, for
health care management and follow-up.
Personal Property
I understand that VU Health Center does not assume responsibility for my personal belongings that I keep
in my possession, and I release VU Health Center from all liability for the loss or theft of, or damage to,
such belongings.
Sharing Information with Family and/or Friends
As a courtesy, limited health information may be shared with family, friends and authorized
representatives under the following conditions: (1) the information is related to patient care or payment
for care, or (2) the information is needed to notify individuals about the patient’s location, general
condition or death. If you prefer VU Health Center not share this information, please initial below.
______ (initial) I do not want personal health information shared with family, friends, and/or
representatives.
I UNDERSTAND MY SIGNATURE CONSTITUTES MY ACKNOWLEDGEMENT THAT: 1) I HAVE
READ AND AGREED TO THE FOREGOING; 2) THE TREATMENTS HAVE BEEN ADEQUATELY
EXPLAINED TO ME BY VU HEALTH CENTER AND THAT I HAVE RECEIVED ALL INFORMATION
I DESIRE CONCERNING THE SAME; 3) THAT I AUTHORIZE AND COSENT TO TREATMENT OR
TEST, AND 4) I AM RELEASING VANGAURD UNIVERSITY AND VU HEALTH CENTER FROM
LIABILITY.
I UNDERSTAND THAT I MAY WITHDRAW THIS CONSENT IN WRITING. MY WITHDRAWAL
WILL NOT BE EFFECTIVE FOR ACTIONS ALREADY TAKEN BY VU HEALTH CENTER, OR IN
PROGRESS. I AUTHORIZE VU HEALTH CENTER TO RELEASE ALL RECORDS REQUIRED TO
ACT ON THESE REQUESTS. I HAVE READ AND UNDERSTAND THIS FORM, RECEIVED A COPY,
AND I AM THE PATIENT OR I AM AUTHORIZED TO ACT ON BEHALF OF THE PATIENT TO SIGN
THIS FORM.
_______________________________________ DATE: ______________TIME:___________
PATIENT SIGNATURE (or Authorized Representative)
PRINTED NAME: ____________________________________________________
RELATIONSHIP, if not patient: ___________________________________________________
WITNESS: _________________________________ DATE: _______________ TIME: ______________
(VU Health Center Employee)
General Consent For Treatment
Medical Records Form
Revised: August 2015