PATIENT DECLARATION OF CONSENT FOR HEALTHCARE SERVICES

I, Name Surname, personal identification number 00000000000, declare the following:

  1. I have been informed that I must provide the healthcare professional with complete and accurate information about my health condition, including information about my current and past illnesses, medications taken or currently used, allergic reactions, previous surgeries, genetic predispositions, and any other information known to me that may be relevant to the provision of healthcare services.

  2. I confirm that I have been ознакомized with the Internal Rules of MB UROLITA.

  3. I have been informed that patients and physicians are not allowed to exchange personal phone numbers or other direct communication contacts. Violation of this rule may result in compensation for material damages to the clinic in the amount of EUR 500 (see Internal Rules).

  4. I confirm that I have been informed about the paid healthcare services provided by MB UROLITA, their pricing, and I agree to pay for the healthcare services that I choose and receive.

  5. I confirm that I have been informed about the qualifications of the healthcare specialists providing services at MB UROLITA, and about my right to choose a healthcare professional.

  6. I have been informed and agree that the physician may perform an assessment of my health condition and other actions necessary for establishing a diagnosis and preparing a treatment and/or examination plan. I have been informed about the scope of such actions.

  7. I have been informed about the procedure for referral to other healthcare institutions.

  8. I have been informed and agree that information related to the services provided by MB UROLITA (for example: appointment time, location, preparation for examinations, laboratory test results) may be sent to my email address and/or mobile phone number.

  9. I have been informed that MB UROLITA provides and/or organizes necessary emergency medical assistance (first aid and urgent care) within its competence free of charge.

  10. I have been informed and agree that separate consent is not required for examinations and tests that do not involve damage to tissue or organ integrity and may cause only minimal temporary effects on my health.

I understand that this consent includes examination and palpation of the conjunctiva of the eyes, ears, mouth, throat, nasal cavities, rectum, vagina, prostate, and genital organs, as well as collection of material for tests from these areas without damaging tissue integrity.

I have been informed about possible risks and complications of such procedures:

  • Common: none identified

  • Rare: mild pain, discomfort, infection

  • Other risks: possible risks specific to the patient depending on their health condition.

  1. I agree that audio recording may be made during the physician consultation for the purposes of ensuring service quality, dispute prevention, and documentation of the consultation. The audio recording will be stored in accordance with personal data protection requirements for up to 10 years.

  2. I agree that my anonymized health data may be used by MB UROLITA for medical analysis, service quality improvement, and scientific research purposes. The data will be anonymized in such a way that my identity cannot be determined.

  3. I agree that the physician of MB UROLITA providing healthcare services to me may access my health records held by other healthcare institutions.

  4. I have been informed that surgeries, invasive and/or interventional procedures, except those mentioned in this declaration, will be performed only after obtaining my separate written consent.

I agree that separate written consent is not required for the following procedures:

  • urethral bougienage

  • removal of postoperative sutures

  • insertion or removal of a urinary bladder catheter and/or nephrostomy

  • urethral dilation

  • injection of Caverject into the penis

I have been informed about possible risks and complications of these procedures:

Common:

  • pain

  • infection

  • bleeding

Rare:

  • local tissue reaction (swelling, redness)

  • allergic reaction

  • orthostatic collapse

  • fainting

  • abscess

  • tissue necrosis

  • inflammation of veins

Other risks: possible risks specific to the patient depending on their health condition.

  1. I UNDERSTAND that during each visit to the physician, the specifics of the examination and treatment methods, as well as possible alternatives, will be explained to me.

If such explanations are not provided or if I do not agree with the proposed examination or treatment plan, I will not undergo the prescribed tests or start treatment and will immediately (within one hour after the consultation) notify the consulting physician and the administration of MB UROLITA in writing (by email: info@urolita.lt and/or SMS to +37066675766).

  1. I agree that information about my visits to MB UROLITA, my health condition, diagnosis, treatment, and other confidential information may be provided to the persons indicated below.

I have been informed that I may withdraw this consent at any time by submitting a written notice to MB UROLITA.

(Name, surname, and optionally the validity period and scope of information disclosure may be specified.)

  1. This document has been explained to me by urologist Name Surname.

  2. The text of this document has been verbally translated into a language that I understand, and its content is clear and understandable to me.

  3. I confirm that the information provided to me by MB UROLITA as specified above (points 1–15) is sufficient and clear.

Having received the above information and by signing this consent, I agree to receive healthcare services.

Date and time of signing the document:
MMMM-MM-DD

If you are representing the patient and acting on their behalf and in their interests, please indicate the legal basis of representation and provide the supporting document.

Patient (or representative)
Name and surname

Signature of the patient (or representative)

I have been informed that the full text of this consent can be read at any time at:
www.urolita.lt/pacientams/sutikimas

Signature of the patient (or representative)

I have been informed that any part of this consent may be withdrawn or modified in writing by contacting MB UROLITA physicians or administration.

Signature of the patient (or representative)