Consent for Treatment

I voluntarily consent to medical care at Vitality Urgent Care and to treatment by the provider on duty — physician, nurse practitioner, or physician assistant — and whoever they may designate as their assistant, associate, collaborating physician, supervised student or trainee, and patient care staff to provide my care. Such care may include, but is not limited to, diagnostic testing, imaging, and the administration of medications considered advisable in my diagnosis, treatment, and course of care. I acknowledge that no guarantees can be made as to the results of treatments or examinations and I understand that all medical treatments contain inherent risks.

If X-ray imaging is medically indicated, I consent to diagnostic X-ray at Vitality Urgent Care. I understand that X-ray involves a small dose of ionizing radiation. If I am pregnant or think I may be pregnant, I will tell my provider before any imaging is performed.

I am aware that the practice of medicine is not an exact science and I acknowledge that no guarantees have been made to me as to the results of my examination or treatment at Vitality Urgent Care. I acknowledge that treatment at Vitality Urgent Care is intended to address specific episodic illnesses or injuries and is not intended to substitute for comprehensive care by a primary care physician or other specialized physicians. To provide the best chance for successful treatment, I accept responsibility to follow the advice of my treating provider, including compliance with medications, discharge instructions, and reevaluation with follow-up or referral to specialty care. I agree to seek care in an Emergency Department of a hospital if my condition substantially changes.

I understand that I may ask questions at any time and that I may refuse or withdraw my consent to any part of my care at any time.

Consent for a Minor or a Patient Who Cannot Consent

If the patient is under 18 years of age, I confirm that I am the patient’s parent (including a parent who is themselves a minor), legal guardian, or an adult authorized in writing by the parent or guardian to consent to the patient’s care, and that I have the authority to consent on the patient’s behalf.

If a minor arrives without a parent or guardian, Vitality Urgent Care will attempt to obtain and document the consent of a parent or guardian by telephone before providing non-emergency care.

I understand that Illinois law permits certain minors to consent to their own health care, including: a married or pregnant minor; a minor parent, for the care of their own child; a minor 12 years of age or older, for the diagnosis and treatment of a sexually transmitted infection or drug or alcohol use; and a minor victim of sexual assault, for related care and counseling (410 ILCS 210). Where a minor lawfully consents to their own care, Vitality Urgent Care will follow Illinois law regarding the confidentiality of those records.

For an adult patient who lacks the capacity to consent, consent may be provided by the patient’s legally authorized representative consistent with the Illinois Health Care Surrogate Act (755 ILCS 40). In a medical emergency, treatment may be provided without prior consent as permitted by law.

Assignment of Insurance Benefits

I hereby authorize payment directly to Vitality Urgent Care from all medical benefits available to me, including major medical, Medicare, private insurance, workers’ compensation, and personal injury coverage. I understand that if my insurance coverage does not cover the services rendered, the services will be billed to me directly. I acknowledge that my financial responsibilities are described in the Vitality Urgent Care Patient Financial Responsibility Form, which I will also review and sign.

SMS Text Messages

I consent to receive SMS text messages from Vitality Urgent Care about my care and account — appointment reminders, visit follow-up, laboratory and prescription notices, and billing notices. Message frequency varies; message and data rates may apply. SMS is voluntary and is not a condition of receiving care or of registration. I may opt out anytime by replying STOP, get help by replying HELP, or contact info@vitalityurgentcare.com or 224.601.5001. I understand standard SMS is not a fully secure channel. Privacy Policy: vitalityurgentcare.com/privacy-policy · Terms: vitalityurgentcare.com/terms-conditions · SMS Program: vitalityurgentcare.com/sms

A photocopy or electronic copy of this agreement is to be considered as valid as an original authorization.

Consent for Treatment & Payment · Version 2.0 · Effective 07.17.2026 · Vitality Urgent Care · 56 W Dundee Rd, Buffalo Grove, IL 60089 · 224.601.5001 · 480 S Rand Rd, Lake Zurich, IL 60047 · 847.350.1291