Patient Name (last, first, MI): Date of Birth (mm/dd/yyyy): Medical Record #:Consent for Services • July 27th, 2020
As either the Patient or the legally authorized representative of the Patient, on behalf of the Patient receiving care in this Physician Group of Arizona, Inc., (PGA) Facility, I make the following consents, understandings, 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 PGA Facility, including IASIS Healthcare and its affiliates.
Patient Name (last, first, MI): Date of Birth (mm/dd/yyyy): Medical Record #:Consent for Services • October 8th, 2020
As either the Patient or the legally authorized representative of the Patient, on behalf of the Patient receiving care in this Physician Group of Arizona, Inc., (PGA) Facility, I make the following consents, understandings, 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 PGA Facility, including IASIS Healthcare and its affiliates.
Douglas C. Walker, D.O., P.C., 300 E 1400 S, Garland, UT 84312 Phone (435) 257-3684Consent for Services • September 2nd, 2022
As Either the Patient or the legally authorized representative of the Patient, on behalf of the Patient receiving care at Douglas C. Walker, D.O., P.C. facility, I make the following consents, understandings, 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.
Office of Counseling & Student Success Consent for ServicesConsent for Services • May 11th, 2021
We want to welcome you as a client and appreciate the opportunity to serve you. This form is an agreement that gives permission to Emmanuel College Office of Counseling & Student Success to provide services to you. It is also designed to provide you with information to answer some of the questions you may have regarding your visits to this office and to help you use our services more effectively. Please read this sheet carefully and direct any questions to Office of Counseling & Student Success personnel.
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
Patient Name (last, first, MI): Date of Birth (mm/dd/yyyy): Medical Record #:Consent for Services • June 30th, 2016
As either the Patient or the legally authorized representative of the Patient, on behalf of the Patient receiving care in this Physician Group of Arizona, Inc., (PGA) Facility, I make the following consents, understandings, 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 PGA Facility, including IASIS Healthcare and its affiliates.
