Consent for Treatment

ODYSSEY TRAVEL HEALTH, PLLC


Thank you for choosing Odyssey Travel Health, PLLC (“Practice”) as your care provider. This form outlines important information regarding your consent to treatment provided by the Practice.

I ___________________________________ (patient name) consent and authorize Practice to provide virtual travel medication consultation by the licensed healthcare professionals of the Practice. I understand that such consultation involves meeting with Practice’s licensed healthcare professionals via telemedicine and discussing recommendations for my trip. I understand that I must go to a pharmacy near me to receive any medications or vaccinations prescribed by the Practice’s licensed healthcare professionals.

I understand that:

  • I have the right to be involved in my care including the legal right to refuse any vaccinations or medications. 

  • I have the right to be informed of the recommendations related to my care being given and to discuss any recommended medications or vaccinations with my provider.

  • I have the right to be informed of the potential risks and benefits of telemedicine and any medications or vaccinations that are recommended for me and possible alternative treatments. 

  • I may be asked by Practice’s providers to give additional informed consent for specific services and procedures. 

  • No guarantees or promises have been made to me by Practice or its providers with respect to the results of the health care services rendered by Practice’s providers to me.

Patient Acknowledgement:

By my signature below, I, the patient or guardian of the patient named above, acknowledge that I have read, understand, and agree to the above Consent to Treatment.

I declare under penalty of perjury under the laws of Washington State that I have the legal right to sign this Consent to Treatment because I am or am the guardian of the patient named above. 


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Patient’s Signature Date


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Print name Date


Date Last Revised: December 15, 2022