Common Contracts
1 similar Registration Form and Agreement contracts
Environmental Health Center of Martha’s Vineyard Registration Form and AgreementRegistration Form and Agreement • February 17th, 2019
Acknowledgement and Authority By my signature below, I consent to treatment as necessary or desirable to the patient named above, including but not restricted to whatever drugs, medicines, laboratory, X-ray or other studies that may be used by the attending physician, nurse, or qualified designates. I also acknowledge full responsibility for the payment of such services and agree to pay for them in full at the time of service unless other arrangements are made. I have read and understand the ‘welcome to VPM’ information and I agree to the terms contained here in and office rules to the best of my ability. I have read and understand the financial responsibility form. I also authorize photograph and videotaping of my progress throughout the course of treatment and for my records only.
