1Legal Agreement
2New Patient Information
3Emergency/Guardian/Alternate/ Contact


This Consent To Medical Treatment And Rendering Of Other Medical Services is a legal agreement between you and St. Augustine’s Medical Service’s Inc (“SAMS”). You hereby authorize and direct SAMS and whomever the doctor on call designates (Caregivers) along with his/her assistants to manage my medical condition.

If any unforeseen condition arises during the course of your hospitalization, for the physicians/doctors judgement to administer and treat; from those now contemplated, you further request and authorize him/her to do whatever he/she deems advisable and necessary in these circumstances. Your medical condition has been explained to you to the degree that you wish to have it discussed.

  1. The nature and character of the proposed treatment, including non-treatment.
  2. The anticipated results.
  3. Possible recognized alternative methods of treatment, including non-treatment.
  4. Recognized serious possible risks, complications and anticipated benefits involved in the proposed and alternative treatments.

You/us hereby authorize and consent to such additional services for me as my attending physician and/or his/her associates and assistants may deem reasonable and necessary, including but not limited to the administration and maintenance and the performance of services such as ultrasounds, x-rays, lab tests etc., that is deemed necessary.

You/us understand that the physicians practicing in the hospital may not be hospital employees or agents of the hospital and that some physicians and surgeons and other providers furnishing services to the patient including the radiologists, anesthesiologists, cardiologists etc., may be independent contractors who establish their own, independent relationship with the patient. Services rendered by such physicians may be billed separately.

You/us, on behalf of yourself, your child, and/or your ward also hereby acknowledge that you (all) have been informed that: Medical care and treatment that you (all) receive at this facility may be provided by the patients private physician or other provider and may include physicians, physicians assistants, advanced registered nurse practitioners or health care practitioners who are not employed by St. Augustine's Medical Service Inc. Any liability that may arise from medical care and treatment provided by these agents or employees is limited by law.

Your/our questions have been answered to your satisfaction. l/us acknowledge that no guarantee, warrantee, or assurance has been made as to the results or cure that may be obtained.

I/we certify that l/we have read this form and understand and agree to its contents and have no further questions.