At this office, we believe patients should always have the freedom to participate in their care at a pace and level that feels right to them. This form is not a judgment—it’s a way to ensure your choices are clearly recorded, understood, and respected by your healthcare team. Your voice is important, and we’re here to support you however you choose to engage. Please be aware of the following:

• Electronic record systems are not foolproof: They may contain errors or omissions if you do not provide accurate, up-to-date information during each visit.
• Active participation is essential: Over reliance on electronic record systems can result in missed real-time updates and personal insights that are critical for accurate care and treatment.
• Electronic record systems do not capture ongoing health changes: They cannot replace your role in monitoring symptoms, medications, and other important health details between appointments.

At this time, you chose not to participate in one or more of the following essential engagement practices:

• Completing pre-appointment paperwork accurately.
• Preparing a chief complaint or reason for the visit.
• Bringing a notebook and recording important information during appointments.
• Accessing and using patient portals to manage medical records and communication.
• Maintaining an updated personal medication lists, an at-home care team, and provider/health history.

Your Decision at This Time

The patient has been informed of the importance of these actions in supporting safer care, improving outcomes, and avoiding unnecessary costs. At this time, the patient has chosen not to move forward with the recommended self-health practices. This decision may affect the quality or timeliness of care. The patient has indicated the following choice(s):