Authorization for Treatment. I hereby consent to and authorize all therapy treatments, which in conjunction with the judgments of the attending physician may be considered necessary or advisable for the diagnosis or treatment of the above named patient at Core Physical Therapy. I realize that I am a integral part of the rehabilitation process and will be sufficiently educated about treatment and alternatives before they are performed. Please initial . Date / _/ Signature (Parent or guardian signature if patient is a minor) Patient Name Patient Information Date:
Authorization for Treatment. I have read, fully understand, and agree to the MJCCA Preschools Authorization for Treatment.
Authorization for Treatment. If your pet becomes ill during his/her stay with us, a veterinarian will examine your dog or cat. We will make every attempt to contact you at the numbers you provide should your pet become ill while with us. Medical treatment will be provided at the discretion of the veterinarian on duty. All costs associated with any medical care given while boarding will be at the owners’ expense and due upon your pet’s release. Abandoned Animals Protocol: All pets must be picked up within 5 days of specified check out date. All efforts to contact owner or agent will be made in a timely manner. See the Pet Lodging Contract for more information regarding the Abandoned Animal Act. Social Media I xxxxx XXX permission to post my pet’s picture or story on social media. (circle one) Yes No This Contract contains the entire agreement between the parties. All terms and conditions of this contract shall be binding on the heirs, administrators, personal representatives and assigns of Owner and VAH. I have read, understand and agree to requirements in Valley Animals Hospital’s Lodging Contract.
Authorization for Treatment. I hereby certify that I have read and that I fully and completely understand this Informed Consent for Neurofeedback Training, and I have signed this Informed Consent knowingly, freely, and voluntarily. I understand the policies, expectations, and nature of this treatment as explained above. Moreover, I certify and state that I have received no promises, assurances, or guarantees from anyone as to the results that may be obtained by any neuropsychological. I understand that while my treatment is designed to be beneficial, this facility makes no guarantees about the outcome of this treatment program. I am willing to make a personal commitment to participate to the best of my ability in all steps of the treatment program, though I understand that I am free to withdraw from this treatment at any time. I understand that my failure to comply with my recommended treatment program (such as assignments and regular participation in sessions) could prevent the treatment from working effectively. ______________________________________________ Patient Signature (Guardian signature if patient is a minor) Date _______________________________________________ Witness (Staff) Date Patient/Client Code of Conduct Agreement The Staff at Neurohealth Associates is fully trained to answer all of your questions regarding scheduling and logistics related to the office. It is of great importance, to all of us, that you be treated with the utmost of respect as demonstrated in our communication style and our willingness to be of assistance. In turn, we ask that you return the same level of respect back to our Staff and our other patients. This is including but not limited to:
Authorization for Treatment. I, authorize treatment by The Talking Place, Child and Adolescent Counseling, LLC. Date: Signature: Relation to Patient:
Authorization for Treatment. In the event of injury or illness, the Applicant authorizes LifePoint Church personnel, staff or designates to seek and obtain such emergency or medical services for people as may be deemed necessary at the time.
Authorization for Treatment. When providing speech language pathology services, health care laws require us to obtain authorization from the patient or parent/guardian to provide services. This authorization is your agreement to allow Talk Play Learn Speech Therapy and its employees to render care within our scope of practice. I agree to allow Talk Play Learn Speech Therapy to provide speech-language pathology services for myself or my child/person in my care. In addition: ☐ I agree to attend scheduled therapy sessions (see attendance policy). ☐ I agree to participate in treatment, as appropriate. ☐ I understand that there may be work assigned for home practice. I agree to engage with home practice to help with treatment goals. Print Client’s/Xxxxx’s Name Print Parent/Guardian’s Name & Relationship to Client Client/Guardian’s Signature Date Sessions An initial evaluation can be provided at the request of the client/client’s parents; however, we are not required to conduct our own independent evaluation to establish a treatment plan in order to bill for our services. ● Parents can provide their child’s school, hospital, and/or previous private practice evaluation report as a means of generating speech goals, if available. ● If the evaluation report is dated one or more years ago, the speech-language pathologist may recommend reevaluation to obtain an updated account of the client’s ability level. ● An updated evaluation is needed to establish goals and provide therapy. Speech Therapy services will be provided based on goals agreed upon by both parties in order to best serve your child. Goals can be established through one or more of the following means: administered evaluations/reports; outside evaluations/reports; observations; and parent requests. In order to ensure the safety of your child during his/her therapy session, it is important that an adult be present during the session. Parents are welcome to observe therapy sessions or to be active participants in therapy as is deemed most appropriate. Session structure: ● sessions are 45 minutes in length. ● first 5 minutes used to review homework and generally check in with family and child; ● work on goals directly, with family member(s) participating or observing; ● last 5-10 minutes used for clean-up/transition and to review skills/strategies the family should work on with the child until the next session. ● Suggestions for carryover activities for families will be provided at the time of the session, or electronically at a later ti...
Authorization for Treatment. Should the need for medical attention arise; (and in case of our unavailability), as parents or legal guardians, we want the MJCCA and/or staff to arrange and authorize medical treatment as necessary for our child. In the event of an emergency, I hereby give permission to the physician selected by the director or other MJCCA official to order x‐rays, routine tests, and treatment for the health of my child. In the event that I cannot be reached in an emergency situation, I hereby give permission for a physician selected by the preschool director or other MJCCA official to hospitalize, secure proper treatment for, and order injections and/or anesthesia and/or surgery for my child. I authorize any physician, nurse or other health care provider to communicate with the staff and director of MJCCA Preschools, or his/her designee, about my child’s medical condition, treatment and/or prognosis. I further authorize the director to discuss any medical conditions with his/her designee, or the child’s teacher when the director, in his / her sole discretion, believes such communication to be in the best interest of the child. I, the parent/legal guardian, assume all risks and hazards incidental to the conduct of activities and transportation to/from the activities. I understand that aspects of the MJCCA preschools & Xxxxx may be physically and emotionally demanding. Both my child(ren) and I agree to follow any and all rules, guidelines, and safety instructions that may be provided by MJCCA staff. I recognize the inherent risk of injury or disability in activities. I understand that each participant must assume the risk of injury or disability that could result from any of these activities. I hereby release, indemnify, defend, save, and hold the MJCCA its officers, directors, trustees, employees, members, agents, and activity providers harmless, with respect to any and all claims or liability for any injury to my child(ren) from participation in any and all activities and all claims by or on behalf of myself, my child(ren), or third parties for loss or damage unless the alleged loss is solely the result of the MJCCA’s gross negligence or misconduct. Parking & Carpool Policy Applicable to Xxxxxxxxx School families only. Note: These policies are subject to change while COVID‐19 restrictions are in place. Full Day Families Upon arrival and dismissal, please park your car in a designated parking place and check in at the school office. We ask that you limit your time in the...
Authorization for Treatment. I hereby give permission to the medical personnel selected by the camp director to order X-rays, routine tests, treatment, and necessary transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named above. This completed form may be photocopied for trips out of camp. I also give permission for routine medical care as per the camp physician’s standing orders for my child at Xxxx Xxxxxx YMCA. I understand the camp fees do not include health and accident insurance and I will be responsible for any and all charges incurred in obtaining prompt medical attention. Signature of parent or guardian_______________________ Date___________ During Resident & Day camp programs, the following medications are kept in stock and are used to treat minor symptoms of illness/ injury. They are administered by a Registered Nurse or Licensed Practical Nurse according to the Standing Orders of our Camp Phy- sician. Please CROSS OUT any medications listed below that you do NOT want to be administered. Acetaminophen (Tylenol) Allegra (Fexofenadine) Anatacids Bacitracin/Antibiotic Cream Benadryl/ Diphenhydramine Betadine Caladryl/Calagel Calamine Lotion Cetirizine/Zyrtec Claritin/Loratadine Cough Drops Epipen Eye Drops Eyewash Gas X (Simethicone) Hydrocortisone Hydrogen Peroxide Ibuprofen (Advil/Motrin) Kaopectate Lice Shampoo Lotrimin/Antifungal Cream Maalox (ALUMINUM HYDROXIDE; MAGNESIUM HYDROXIDE; SIMETHICONE) Miralax (Polyethylene Glycol) Natural Tears Oragel Pepto-Bismol (Bismuth Robitussin (dextromethorphan / guaifenesin) Sudafed ( pseudoephedrine hydrochloride ) Sun Burn Spray Sun Screen Throat Lozenges Zinc Oxide Medication Authorization : subsalicylate) I hereby give permission to Xxxx Xxxxxx YMCA medical personnel to administer any of the above medications or their generic equiva- xxxxx not crossed out per the directions of the Camp Physician. Signature of parent or guardian_______________________ Date___________ When Bringing Medication to Camp: Connecticut State Law now requires an authorized prescriber’s (M.D., Dentist, P.A., A.P.R.N.) written order AND parent or guardian’s authorization for a nurse or camp personnel with current Medication Administration Training to administer medications brought from home. Prescription medications must be in the pharmacy prepare...
Authorization for Treatment. All procedures will be thoroughly explained to you before they are performed. There are certain inherent risks with Physical Therapy treatment because you will be asked to exert effort and perform activities with increasing degrees of difficulty, which could cause an increase in your current level of pain or discomfort or an aggravation to your existing injury. There is also a possibility that you could experience a new injury, but this risk is small. You will be able to control any procedure by stopping if you feel any increase in pain or discomfort. The Physical Therapist will take every precaution to ensure that you are protected from any hazardous situation. You will never be forced to perform any procedure that you do not wish to perform. Based on the above information I agree to cooperate fully and to participate in all Physical Therapy procedures and to comply with the plan of care as it is established. NOTICE TO PATIENTS: For personal safety, do not use any equipment without a staff member present. Initial NOTE: Your deductible/co-pay/co-insurance will be collected at each visit unless otherwise stated. It would be in violation of FPC’s agreement with the insurance company if your payment is not received at the time of service. If your account has an outstanding balance and we have made our attempts to collect that balance, we will forward your account balance onto our collection agency at which time you will be responsible for paying the collection fees (25% of your balance due) as well as your outstanding balance. A $30 Service Fee will be charged on all returned checks. The information obtained from my insurance company by The Functional Performance Center is only a description of benefits - not a guarantee of payment. I am responsible for any fees not covered by my insurance company. Patient/Legal Guardian Signature Date 0000 XXXXX XXXXXXXXXX XXXXX, XXXXX 0 ▪ TEMPE, AZ 85282
