Consent to medical intervention


on the types of medical interventions included in the List of certain types of medical interventions for which citizens give informed voluntary consent when choosing a doctor and a medical organization for receiving primary health care

I, a capable person who has reached the age of fifteen, hereby, for the purpose of fulfilling the terms of the Agreement for the provision of paid medical services with JSC "Clinic for active aging" Institute of Beauty on Arbat "(OGRN 1027700056207, TIN 7704199040, location address: 119002, Moscow, small nikolopeskovskiy per., 8) on the terms of the Offer posted at, to which this Consent is attached, I give informed voluntary consent to the types of medical interventions included in the List of certain types of medical interventions to which citizens give informed voluntary consent when choosing a doctor and a medical organization for receiving primary health care, approved by order of the Ministry of Health and Social Development of the Russian Federation dated April 23, 2012 N 390n (registered by the Ministry of Justice of the Russian Federation on May 5, 2012 N 24082) (hereinafter - the List) , for receipt by me and / or a person legally represented The author of which I am (the Patient), primary health care in accordance with the terms of this Agreement in the selected Medical Organization.

P / p No.

Type of medical intervention

1. Interview, including identification of complaints, collection of anamnesis

2. Examination, including palpation, percussion, auscultation, rhinoscopy, pharyngoscopy, indirect laryngoscopy, vaginal examination (for women), rectal examination.

3. Anthropometric studies (height, weight, head circumference, etc.).

4. Thermometry (measurement of body temperature).

5. Tonometry (pressure measurement).

6. Non-invasive examinations of the organ of vision and visual functions.

7. Non-invasive examinations of the organ of hearing and auditory functions

8. Investigation of the functions of the nervous system (sensory and motor spheres).

9. Laboratory methods of examination, including clinical, biochemical, bacteriological, virological, immunological, cytological, histological, etc., including sampling of blood, urine, feces, saliva, sweat and other biological fluids and tissues

10. Functional examination methods, including electrocardiography, 24-hour blood pressure monitoring, daily electrocardiogram monitoring, spirography, pneumotachometry, peakfluometry, reoencephalography, electroencephalography, cardiotocography (for pregnant women), ultrasound with vaginal and rectal sensors, etc.

11. X-ray examination methods, including fluorography (for people over 15 years old) and radiography, ultrasound examinations, Doppler studies, computed tomography (CT), X-ray and ultrasound, densitometry, Magnetic resonance imaging (MRI) and other radiation methods of research

12. The introduction of drugs as prescribed by a doctor, including intramuscularly, intravenously, subcutaneously, intradermally, into the joints, by electrophoresis, etc.

13. Medical massage and acupuncture.

14. Physiotherapy.


  • I have been explained the goals, methods of providing medical care, associated risks, possible options for medical interventions, their consequences, including the likelihood of complications, as well as the expected results of medical care.
  • I have been informed (a) about the goals, nature and adverse effects of the proposed medical intervention, diagnostic and therapeutic procedures and the possibility of unintentional harm to my health during their implementation, as well as about what I (represented) have to do during their implementation;
  • I understand the need for this medical intervention. It is completely clear to me that during the manipulation (procedure) or after it complications may develop, which may require additional interventions (treatment), for which I consent to my doctors.
  • I have been warned and am aware that refusal of treatment, non-compliance with the medical and protective regime, recommendations of medical workers, the regimen of taking medications, unauthorized use of medical instruments and equipment, uncontrolled self-medication can complicate the treatment process and adversely affect the state of health:
  • I authorize physicians to perform any procedure or additional intervention that may be required for the purposes of treatment and diagnosis, as well as in connection with the occurrence of unforeseen situations in the process of providing me (represented) with medical intervention.
  • I have been notified. that I (my representative) need to regularly take prescribed medications and other methods of treatment, immediately inform the doctor about any deterioration in health, agree with the doctor to take any non-prescribed medications
  • I am familiar with the procedure and rules of the medical and protective regime established in this medical and preventive institution, and I undertake to comply with them;
  • I informed the doctor about all health-related problems, including allergic manifestations or individual intolerance to drugs, about all the injuries, operations, diseases I have experienced and known to me, about environmental and industrial factors of physical , of a chemical or biological nature, affecting me (represented) during my life, about the medications taken. I have reported (a) truthful information about heredity, as well as about the use of alcohol, drugs and toxic substances;
  • I have been notified of the possibility of receiving the appropriate types and volumes of medical care without charging a fee within the framework of the program of state guarantees of free provision of medical care to citizens and the territorial program of state guarantees of free provision of medical care to citizens;
  • I consent to the provision of medical care on a paid basis;
  • I agree to the conduct of medical intervention by other medical professionals, including employees of other Medical organizations, taking into account the preservation of medical secrecy.

It has been explained to me that I have the right to refuse one or more types of medical interventions included in the List, or to demand its (their) termination, except for the cases provided for by part 9 of Article 20 of the Federal Law of November 21, 2011 N 323-FZ " On the basics of protecting the health of citizens in the Russian Federation. "

This consent was provided to JSC "Clinic for active longevity" Institute of Beauty on Arbat "by me on the terms of the Offer to conclude an agreement for the provision of paid medical services, by putting a mark I agree (" tick ") on the website using a simple electronic signature, and is equivalent paper document signed with a handwritten signature.