Common use of TREATMENT AGREEMENT Clause in Contracts

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and the effectiveness of treatment. I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be pregnant or breastfeeding during the treatment and for 6 months after treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate for evaluation of my health and well-being during treatment and the effectiveness of treatment. I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be pregnant or breastfeeding during the treatment and for 6 months after treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and the effectiveness of treatment. I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 12). As a female, I understand that I cannot be pregnant or breastfeeding during the treatment and for 6 months after treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate for evaluation of my health and well-being during treatment and the effectiveness of treatment. As a female taking Harvoni®, I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be get pregnant or breastfeeding during the treatment and for 6 months after breastfeed while on treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I have not abused alcohol or other substances (intravenous drugs, cocaine, prescription pain medications) within the last 6 months. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). Failure to tell my provider about my medical and psychiatric conditions can have life-threatening consequences during this treatment. I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and the effectiveness of treatment. I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be pregnant or breastfeeding during the treatment and for 6 months after treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to the treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I have not abused alcohol or other substances (intravenous drugs, cocaine, prescription pain medications) within the last 6 months. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and the effectiveness of treatment. As a female taking Harvoni®, I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be get pregnant or breastfeeding during the treatment and for 6 months after breastfeed while on treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and the effectiveness of treatment. As a female taking Zepatier™ I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be get pregnant or breastfeeding during the treatment and for 6 months after breastfeed while on treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I have not abused alcohol or other substances (intravenous drugs, cocaine, prescription pain medications) within the last 6 months. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). Failure to tell my provider about my medical and psychiatric conditions can have life-threatening consequences during this treatment. I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and the effectiveness of treatment. I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be pregnant or breastfeeding during the treatment and for 6 months after treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to the treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I have not abused alcohol or other substances (intravenous drugs, cocaine, prescription pain medications) within the last 6 months. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and the effectiveness of treatment. As a female taking Viekira Pak®, I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be get pregnant or breastfeeding during the treatment and for 6 months after breastfeed while on treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate for evaluation of my health and well-being during treatment and the effectiveness of treatment. As a female taking Epclusa®, I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be get pregnant or breastfeeding during the treatment and for 6 months after breastfeed while on treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and the effectiveness of treatment. I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I canwill not be get pregnant or breastfeeding during the treatment and for 6 months after breastfeed while on treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: . I agree not to drink alcohol or use recreational drugs during the treatment. I have not abused alcohol or other substances (intravenous drugs, cocaine, prescription pain medications) within the last 6 months. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). Failure to tell my provider about my medical and psychiatric conditions can have life-threatening consequences during this treatment. I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my the Liver Clinic provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and the effectiveness of treatment. I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be pregnant or breastfeeding during the treatment and for 6 months after treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin male, I understand that I should not father a child during treatment and for 6 months after treatment. I understand that I need to use 2 methods of birth control (see list, page 1) because this treatment can cause harm to a baby I father during treatment and up to 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to pursue the treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatmentI acknowledge that I have received, please review have read (or have had read to me), and understand the following statements Psychotherapy Services Agreement & Consent to Treat, Notice of Privacy Practices, and initial beside disclosure of Vermont State Statutes, regarding the responses: therapy I agree not to drink alcohol or use recreational drugs during the treatmentam considering. I will tell have had all my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis)questions answered fully. I am willing do hereby seek and consent to visit take part in the clinic and see a provider on a regular schedule for treatment by the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointmenttherapist named below. I understand that developing a treatment plan with this therapist and regularly reviewing our work toward meeting the treatment goals are in my best interest. I agree to play an active role in this process. I understand that no promises have been made to me as to the results of treatment or of any procedures provided by this therapist. I am aware that I may stop my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and with this therapist at any time. In the effectiveness event of treatment. I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a femaleterminating services, I understand that I canwill be responsible for paying for the services that I have already received. I know that I must call to cancel an appointment at least 24 hours before the time of the appointment. If I do not attend a scheduled session, I may be pregnant charged a fee up to that of the hourly rate for my session. I am aware that an agent of my insurance company, other third-party payer, agent of a third-party billing service, or breastfeeding during other third-party provider may be given information about the treatment type(s), cost(s), date(s), and providers of any services or treatments I receive for 6 months after the purposes of treatment, payment, and healthcare operations. I understand that my treatment will be stopped if payment for the services I become pregnant. Not applicablereceive here is not made, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C therapist may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposuretreatment. My signature below means shows that I understand and agree with all of these statements. Signature of client (or person acting for client) Date Printed name Relationship to client (if necessary) I, the therapist, have read discussed the issues above with the client (and/or his or her parent, guardian, or other representative). My observations of this treatment agreement and/or the meaning person's behavior and responses give me no reason to believe that this person is not fully competent to give informed and willing consent. Signature of the therapist Date • Copy accepted by client • Copy kept by therapist This is a strictly confidential client medical record. Redisclosure or transfer is expressly prohibited by law. NOTICE OF PRIVACY PRACTICES This notice describes how clinical and medical information has been explained about you may be used and disclosed and how you can get access to methis information. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature DatePlease review it carefully.

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: I agree not to drink alcohol or use recreational drugs during the treatment. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and the effectiveness of treatment. I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be pregnant or breastfeeding during the treatment and for 6 months after treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of the information has been explained to me. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date

TREATMENT AGREEMENT. To receive treatment, please review the following statements and initial beside the responses: . I agree not to drink alcohol or use recreational drugs during the treatment. I have not abused alcohol or other substances (intravenous drugs, cocaine, prescription pain medications) within the last 6 months. I will tell my provider if I have any serious medical conditions (such as heart disease, high blood pressure, diabetes, high cholesterol, rheumatoid arthritis, or drug addiction), or psychiatric conditions (depression, history of suicide attempts, bipolar disorder, or psychosis). I am willing to visit the clinic and see a provider on a regular schedule for the entire length of the treatment. If I am unable to attend an appointment, I will let my provider know this ahead of time and I will reschedule my appointment. I understand that my treatment will be stopped if I cannot attend appointments as required to evaluate my health and well-being during treatment and the effectiveness of treatment. I will use 2 acceptable methods of birth control during treatment and for 6 months after I stop treatment (see lists, page 1). As a female, I understand that I cannot be pregnant or breastfeeding during the treatment and for 6 months after treatment. I understand that my treatment will be stopped if I become pregnant. Not applicable, I am surgically sterile or post-menopausal. As a male taking ribavirin I understand that I should not father a child during treatment and for 6 months after treatment. If I have any problems with the medications or side effects that bother me, I will let my provider or nurse know right away. I understand that my hepatitis C may not respond to treatment. I understand that my provider can stop my treatment if the provider feels that stopping it is in the best interest of my health and welfare. I will do my best to take my medications as prescribed by my provider. If I am unable to do so, I will contact my provider. I will protect myself and others from hepatitis C by not sharing needles, toothbrushes, razors or nail clippers and covering cuts to prevent blood exposure. My signature below means that I have read this treatment agreement and/or the meaning of meaningof the information has been explained to me. I agree to treatment. Patient’s Name (PLEASE PRINT) Patient’s Signature Date