Client Consent. My signature below indicates that I reviewed this document, agree to the policies, and authorize the services. I accept financial responsibility for payment of services received, and for payment of late cancellations. If I use insurance to pay all or a portion of the charges, I hereby authorize the release of information necessary to process insurance claims filed on my behalf. I acknowledge that I am financial and legally responsible for the full payment of charges for services received in the event my health insurance policy does not cover my claim. I am 18 years of age or older or I have legal custody of this minor child(xxx). xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully.
Client Consent. I/We understand and consent to the above terms and I hereby authorise the transfer of information, as described above on a confidential basis when warranted between such third parties. I/We agree that the Client Agreement will come into effect from the date of issue.
Client Consent. My signature below indicates that I reviewed this document, agree to the policies, and authorize the services. I accept financial responsibility for payment of services received, and for payment of late cancellation fees. If I use insurance to pay all or a portion of the charges, I hereby authorize the release of information necessary to process insurance claims filed on my behalf. I acknowledge that I am financial and legally responsible for the full payment of charges for services received in the event my health insurance policy does not cover my claim. I am 18 years of age or older or I have legal custody of this minor child(xxx). Client Signature: Date: Custodial Parent or Guardian Signature: Date: Therapist Signature: Date: xxxx@xxxxxxxxxxxxxxxxx.xxx • xxx.xxxxxxxxxxxxxxxxx.xxx Care and Counseling offers the option to receive an appointment reminder the day prior to your scheduled appointment by email (up to 2 email addresses) and/or by phone (only 1 phone number permitted). If you choose the reminder by phone, you have the option of a text message or a computer-generated voice message. PHONE REMINDER (only one type of phone reminder can be provided): Text Message: I authorize Care and Counseling to send text message appointment reminders to me on my provided cell phone number. Text message charges from my cell phone provider may apply. Cell phone number to send text messages to: ( ) - Automated Voice Messages: I authorize Care and Counseling to send computer generated voice phone message appointment reminders to me on my provided phone number.
Client Consent. The Client hereby grants to the Department of Waste Management and its employees, the permission to enter upon and use the venue for the purpose of delivery and removal of litter bins.
Client Consent. This document is our standard client agreementupon which we intend to rely. For your own benefit and protection you should read these termscarefully before signing them. If you do not understand any point please ask for further information. I/We consent to the terms set out above.
Client Consent. This is our standard client agreement upon which we intend to rely. For your own benefit and protection you should read these terms carefully before signing them. If you do not understand any point please ask for further information. Please tick this box if you do not consent to us or any company associated with us processing any such sensitive data. Please tick this box if you do not wish for us or any company associated with us to contact you for marketing purposes by e-mail, telephone, post or SMS. I/We are aware of the costs of the Financial Advice, the Policy Arrangement and Implementation services and agree to the method and timing of these. By deduction from the policy I/We confirm that we agree to the adviser being remunerated on the basis selected below; By direct payment from ourselves Client 1 Name ....................................................
Client Consent. 27 Section 6.2 Conduct of Business................................................................ 27 Section 6.3 Preservation of Business and Assets................................................ 28 Section 6.4 Standstill......................................................................... 29 Section 6.5
Client Consent. Client hereby grants Babette’s and its employees, to enter the Property for the purpose of providing a design consultation.
Client Consent. Declaration
Client Consent. How am I supposed to explain to clients why I am asking them to share their personal information with me?
