Consent for Treatment. You consent to mental health care as provided by Synergism Counseling as directed by the mental health professional. You understand that due to factors beyond our control, such benefits and desired outcomes cannot be guaranteed. A variety of treatment methods will be used to provide relief of your symptoms and to improve coping and problem solving skills.
Consent for Treatment. Consumers 14 years of age or older may consent for their own mental health services for up to 12 weeks or 4 months without parental/guardian consent or notification per Michigan law. For consumers under the age of 14, parental/guardian consent will be obtained either by the agency or the provider prior to providing services.
Consent for Treatment. CONTRACTOR will obtain a signed “consent to treatment” form that includes consent for treatment services for each client covered by this AGREEMENT using a legally adequate consent form or format pursuant to California Welfare and Institutions Code section 5326.2 or any other statute or regulation if applicable.
Consent for Treatment. Most people benefit by participating in mental health services; however, there is no guarantee that you or your family members will be helped. I give consent for treatment.
Consent for Treatment. I authorize the staff of Boise State University Health Services, their employees, and consultants to undertake such treatment, diagnostic procedures, and medical procedures, which in their judgment may become necessary while receiving care at Health Services. I understand that I will be involved and engaged in my care and treatment; and that I have a right to a full explanation of any treatment or procedures utilized. I am aware the practice of medicine is not an exact science and I understand no guarantees have been made to me regarding the results of treatment or examinations. As a patient/client of Health Services, I understand that individuals being trained for a health care profession may participate in providing me care. I understand that if I require specialized care, emergency care, or care which is out of the scope of services for Health Services I will be referred to the appropriate facility and/or providers. I understand that an emergency contact will be notified of my condition if considered necessary by the professional staff at Health Services.
Consent for Treatment. I consent to telehealth care performed by my physician and all other associated health care providers at Endocrinology Specialists of Colorado (“ESC”) (the “Providers”). This includes examinations, diagnostic testing, treatment, and other health care services deemed medically necessary in the Providers’ professional judgment. I understand that the practice of medicine and surgery is not an exact science and that diagnosis and treatment may cause injury or even death. I also understand that I have the option to refuse the delivery of health care services by telehealth at any time without affecting my right to future care or treatment, and without risking the loss or withdrawal of any benefits to which I would otherwise be entitled. If I am pregnant, this consent also applies to my fetus.
Consent for Treatment. I, , the undersigned, do hereby authorize and give consent to UNM to provide health care, medical treatment and procedures to the Patient which may include but is not limited to the following:
Consent for Treatment. My signature on this page indicates that I am consenting to enter into treatment with Xxxxxxx Xxxxxxx, LMFT. I acknowledge that I have reviewed and fully understand the terms and conditions of this Agreement. I have discussed such terms and conditions with Xxxxxxx Xxxxxxx, LMFT and have had any questions with regard to its terms and conditions answered to my satisfaction. I agree to abide by the terms and conditions of this Agreement and consent to participate in psychotherapy and agree to authorize this practitioner to conduct diagnostic procedures, psychological assessments, and treatment procedures throughout my course of treatment. I also understand that the outcome of my treatment cannot be guaranteed, even though psychotherapy is designed to be helpful. Moreover, I agree to hold Xxxxxxx Xxxxxxx, LMFT free and harmless from any claims, demands, or suits for damages from any injury or complications whatsoever, save negligence, that may result from such treatment. Patient Name (please print) Signature of Patient (or authorized representative) Date I understand that I am financially responsible to Xxxxxxx Xxxxxxx, LMFT for all charges Name of Responsible Party (Please print) Signature of Responsible Party
Consent for Treatment. I hereby authorize Eastern Shore Foot & Ankle Center to examine, treat, and perform diagnostic tests and office procedures that the physician deems necessary. Privacy Practices: Eastern Shore Foot & Ankle Center is required by law to maintain the Privacy of a patient’s protected health information. In addition we are required by law to provide individuals with this notice of our legal duties and privacy practices with respect to protected health information. You must notify us in writing of any restrictions on the release of your protected health information I have read and agree to the above. My signature below indicated that I have also received a copy of the Eastern Shore Foot & Ankle Center Notice of Privacy Policies and I have indicated any restrictions of my Protected Health Information. Scanned signatures suffice as originals. Patient Signature Date
Consent for Treatment. I AUTHORIZE Plumtree Family Health Center, LLC to provide me with medical care and treatment. Please acknowledge receipt and review of this section by signing initials. X By Signing below I have read and agree to the term of this entire agreement. Patient Signature\Guardian: Relationship to Patient: Date: 000 Xxxxxxxx Xxxx, Xxxxx 000, Xxx Xxx, Xxxxxxxx 00000 Phone 000-000-0000 Fax 000-000-0000 xxx.XxxxxxxxXxxxxx.xxx
