Consent to Treatment. The Boys Town Behavioral Health Clinic works with children and their families to identify and treat such issues as depression, anxiety, school problems, and ADHD. The Behavioral Health Clinic offers specialized services, including behavioral and psychological assessments as well as counseling. I, knowing that the client has a condition requiring diagnosis and treatment, do hereby voluntarily consent to such treatment by the Behavioral Health Clinic staff, assistants, or designees as is, in their judgment, necessary. I further acknowledge that no guarantees have been made to me as to the results of treatment. I authorize you to provide reasonable and proper care by today’s standards. If applicable, I have informed my treating provider of my mental health advance directives and have provided a copy for mental health decision-making that will become part of my treatment record. CONTACT BY TELEPHONE and EMAIL
Consent to Treatment. An admission contract must not include a clause requiring a resident to sign a consent to all treatment ordered by any physician. An admission contract may require consent only for routine nursing care or emergency care. An admission contract must contain a clause that informs the resident of the right to refuse treatment.
Consent to Treatment. Sponsor and the coaches/trainers are hereby authorized to, in the exercise of their reasonable judgment, to facilitate the rendering of first aid and/or medical assistance in the event of an injury to Player. Player understands and agrees that the rendering of any medical or other services to Player, or at the instance of, by Sponsor or any coach, trainer or any person/entity identified in Paragraph 7 above, is not an admission of liability to provide or to continue to provide any such services and is not a waiver of any right(s) hereunder.
Consent to Treatment. In further consideration of being permitted to participate in intercollegiate athletics, I hereby authorize and consent to such diagnostic, medical and/or surgical treatment as may be considered necessary or appropriate under the circumstances for the treatment of any illness or injury arising from or sustained by me while engaged in activities related to intercollegiate athletics. The attending physician(s), athletic trainers(s), appropriate staff, and SSU and its officers, agents, and employees shall not be responsible in any way for ay consequences from said diagnostic, medical and/or surgical treatment and are hereby released from any and all claims of causes that may arise, grow out of, or be incident to such diagnosis and treatment, to the full extent allowed by law.
Consent to Treatment. I consent to the administration of health care by South Bend Orthopaedics This consent to treatment includes the administration of health care by the physicians employed by or associated with South Bend Orthopaedics and such assistants, residents, interns, students, or other medical personnel as may be selected and supervised by said South Bend Orthopaedics physicians. I understand that I may set condition or limitations on my treatment and care and that if I wish to provide such conditions, I will be given an opportunity to write those in a separate document. I understand that during the course of treatment, my blood or bodily fluids may come in contact with a care giver. Upon such an exposure incident testing may be necessary to determine my Hepatitis and HIV status and I give my consent for such testing. I am giving my consent to the administration of health care by South Bend Orthopaedics voluntarily. I have been informed and acknowledge that I may withdraw my Consent to Treatment at any time upon written notice to South Bend Orthopaedics. I hereby knowingly and voluntarily enter into this Consent to Treatment. By my signature below, I am acknowledging receipt of a copy of this document and agree to the terms under all sections of this document: Agreement to Pay and Benefit Assignment, Notice of Financial Interest in Health Care Entity, Consent to Treatment, and Acknowledgment of Receipt of HIPAA Privacy Policies. Signature of Patient/Guardian/Personal Representative Date Employee Witness
Consent to Treatment. The Resident hereby consents to routine nursing care provided by this Facility, as well as emergency care that may be required. However, you have the right, to the extent permitted by law, to refuse any treatment and the right to be informed of potential medical consequences should you refuse treatment. We will keep you informed about the routine nursing and emergency care we provide to you, and we will answer your questions about the care and services we provide you. If you are, or become, incapable of making your own medical decisions, we will follow the direction of a person with legal authority to make medical treatment decisions on your behalf, such as a guardian, conservator, next of kin, or a person designated in an Advance Health Care Directive or Power of Attorney for Health Care. Following admission, we encourage you to provide us with an Advance Health Care Directive specifying your wishes as to the care and services you want to receive in certain circumstances. However, you are not required to prepare one, or to provide us a copy of one, as a condition of admission to our Facility. If you already have an Advance Health Care Directive, it is important that you provide us with a copy so that we may inform our staff. If you do not know how to prepare an Advance Directive and wish to prepare one, we will help you find someone to assist you in doing so. State of California – Health and Human Services Agency Department of Health Services
Consent to Treatment. I/We hereby authorize and request that Xxxxxx Xxxxxxxxx, MSW, LCSW carry out mental health examinations, treatments, and/or diagnostic procedures which now or during the course of my care are advisable. I/We understand that the purpose of these procedures will be explained to me and be subject to my agreement. I/We understand that I am consenting and agreeing only to those services that the above named provider is qualified to provide within the scope of the provider's license, certification, and training. If the patient is under 18 or unable to consent to treatment, I attest that I am authorized to initiate consent for treatment and/or legally authorized to initiate and consent to treatment on behalf of this individual. Process of Evaluation and Treatment: You will be evaluated based on the information that you (and/or your parent or guardian) provide. You and your therapist will come up with a Treatment Plan based on this information along with the therapist’s assessment of the symptoms and problems presented. Therapy is a unique experience for each person and the results depend greatly on the collaboration between the therapist and the client or clients. You may be asked for your feedback and views on your therapy, its progress, and other aspects of your treatment. Your honesty and openness with your clinician will help determine which approach(es) are the best course of treatment for you. Try to think of the relationship as a partnership focused on you! Termination: Therapy usually ends when the therapist and the client agree that the treatment goals have been reached. Sometimes life changes bring out further issues to address. At any time during treatment it may be determined that your specific needs require you to be referred to another healthcare provider. Referrals will be provided if it is medically necessary, or if you or your therapist believe that your treatment is not effective in helping you reach your therapeutic goals. You have the right to terminate therapy at any time. Your therapist will provide you with the numbers of treatment providers that you may prefer at your request. If you choose to and authorize in writing, your therapist will assist with you in communicating with the treatment provider of your choice verbally or in writing. Minors: Please note that the records of a minor or person under the care of a legal guardian are accessible to the parent or guardian. The therapist can withhold certain information if it is in the best int...
Consent to Treatment. I consent to receive medical and/or cosmetic health care services provided by Xxxx Xxxxxxx Dermatology (AADerm”) entities. I understand that such services may include but are not limited to examination and treatment of skin disorders, performing cryosurgery, shave biopsies, punch biopsies or other minimally invasive testing on lesions, and sending specimens to a pathology or other lab for diagnosis. I authorize the examination, use, storage and disposal of all tissue, fluids,
Consent to Treatment. School will be responsible for gathering and providing to Hospital a signed copy of the consent to medical treatment form for all participants in the School's athletic programs.
Consent to Treatment. 3.1 I agree that if I suffer injury the Releases’ may at my expense arrange for me to receive medical treatment and emergency evacuation services as the Releases’ deem appropriate and I understand that any personal injury that I incur may be worsened or compounded by not only my actions but by the actions, omissions or negligence of others.
3.2 I agree that I am responsible for my own medical and ambulance insurance as well as insurance for my personal belongings.
