Common Contracts

2 similar Consent for Treatment and Authorization for Release of Medical Information contracts

AGREEMENTS AND AUTHORIZATIONS
Consent for Treatment and Authorization for Release of Medical Information • July 22nd, 2021

Are your symptoms? □ Constant □ Comes and goes daily □ Occasional (less than daily) □ Sporadic (less than weekly) Symptom Description: □ Aching □ Stabbing □ Burning □ Dull □ Steady □Throbbing □ Numbness/Tingling □ None of these Can you get comfortable at night? □ Yes □ No Does time of day affect your symptoms? □ Yes □ No

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AGREEMENTS AND AUTHORIZATIONS
Consent for Treatment and Authorization for Release of Medical Information • May 13th, 2021

Are your symptoms? □ Constant □ Comes and goes daily □ Occasional (less than daily) □ Sporadic (less than weekly) Symptom Description: □ Aching □ Stabbing □ Burning □ Dull □ Steady □Throbbing □ Numbness/Tingling □ None of these Can you get comfortable at night? □ Yes □ No Does time of day affect your symptoms? □ Yes □ No

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