Management plan (Services inside the clinic including injections and investigations)
Doctor’s Name and signature with seal:
Diagnostic Procedures referred outside:
I hereby authorize the physician, Hospital or pharmacy to file a claim for medical services on my behalf and I confirm that the abovementioned examination/Investigation/therapy is given to me by the doctor. I hereby authorize any Clinic, Physician, Pharmacy or any
other person who has provided medical services to me to furnish any and all information with regard to any medical history, medical condition,
or medical services and copies of all medical and Clinic records.
Date
Signature of the Patient
Pharmaceuticals (to be filled by treating doctor only)