Common Contracts
1 similar Consent for Services contracts
CONSENT AND CONDITIONS OF SERVICEConsent for Services • March 7th, 2014
PATIENT NAME (LAST, FIRST, MI) DATE OF BIRTH (MO/DAY/YR) OFFICE USE - ACCOUNT NUMBER As either the Patient or the legally authorized representative of the Patient, on behalf of the Patient receiving care in this MLR facility, I make the following consents, understanding, and agreements on my own behalf and on behalf of the Patient, in partial consideration of health care services to be provided to the Patient in the Facility: Consent for Services: I hereby give consent to the Facility, its contractors, therapist, and employees to provide health care services to the Patient for the benefit of the Patient for this visit and any subsequent visits. I understand this consent may be revoked in writing at any time. I understand that there is a risk of substantial and serious harm involved in such health care services, and I accept such risk in the hope of obtaining beneficial results from such services. No promises of any particular outcome or successful result have been made. I understand an
