I voluntarily present for treatment and consent to my physician and whomever they may designate, associate, treating physician and patient care staff to provide my care. Such care may include, but not limited to, diagnostic procedures, psychotherapeutic treatment, other treatments and medications, pathologic and radiological evaluations and procedures considered advisable in my diagnosis, treatment and course of care.

I acknowledge that no guarantee can be made or has been made as to the results of treatments or examinations.

In addition to the release and uses of my health information described in the HIPAA Notice of Privacy Practices, I authorize the release of my medical records, information, treatment and advice, and specific health information to:

I understand the information concerning medical care, advice or treatment may include: history, physical, diagnosis, laboratory and diagnostic testing, specific information concerning alcohol abuse, mental health, drug abuse, human immune-deficiency virus, hepatitis, or other infectious diseases.

I understand that I have the right to revoke this authorization at any time.

I hereby authorize the release of my health records:

I understand that the information in my health record may include information relating to sexually transmitted disease, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV). It may also include information about behavioral or mental health services, and treatment for alcohol and substance abuse.

REVOCATION: I understand that this authorization may be revoked in writing at any time, except to the extent that actions have already been taken in response to this authorization for the purposes stated above.

Unless otherwise indicated, this authorization will expire in 90 days from date of signature. The physician and employees are released from any legal responsibility or liability for disclosure to the above information to the extent indicated and authorized herein.

Medical Care is not conditional upon the signing of this authorization.

I understand that there may be a fee for preparing and furnishing this information.

I understand that my medical records may contain reports, test results and notes that only a physician can interpret. I understand and have been advised that I should contact my physician regarding the entries made in my medical record to prevent my misunderstanding of the information contained in these entries. I will not hold Advanced Medical Center liable for any misinterpretation of the information in my medical record as a result of not consulting my physician for the correct interpretation.

A cancellation made with less than a 24 hour notice significantly limits our ability to make the appointment available for another patient in need. Therefore, Town Center Medical Services, LLC dba Advanced Family Practice has instituted an Appointment Cancellation Policy:

Patients are required to provide our office with a 24 hour notice in the event that you need to cancel or reschedule your appointment. This will allow us the opportunity to provide care to another patient. Our office can be reached at 386-431-6690. Please leave a detailed message if an employee is unable to answer your call.

1. A "No-Call", "No-Show" or missed appointment, without proper 24 hour notification, may be assessed with a $35 fee.
2. This fee is not billable to your insurance.
3. If you are 15 or more minutes late for your appointment, the appointment may be cancelled and rescheduled. The applicable fee may be assessed to the patient.
4. As a courtesy, we make reminder calls for appointments, one to two days in advance. Please note, if a reminder call or message is not received, the cancellation policy remains in effect.
5. Repeated missed appointments may result in termination of the physician/patient relationship.