AGREEMENTS AND AUTHORIZATIONSConsent for Treatment • 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
Consent for TreatmentConsent for Treatment • October 16th, 2014
This agreement is intended to provide with important information regarding the practices, policies, and procedures of Suzanne G. Gorter, MFT, and to clarify the terms of the professional therapeutic relationship between Therapist and Client. Do not hesitate to discuss any questions or concerns that you have with the content of this agreement prior to signing.
CONSENT FOR TREATMENTConsent for Treatment • May 20th, 2020
Permission for Diagnosis and Treatment - I hereby give consent to the authorities of The HSC Pediatric Center for such diagnostic procedures, treatment and therapeutic activities.
CONSENT FOR TREATMENTConsent for Treatment • March 17th, 2021
INFORMED CONSENT: This contract explains the conditions that you, as the client, have agreed upon when obtaining services through Center for Psychological Wellness, Inc. (hereafter referred to as CPWI). Some of these rights and obligations are imposed by Florida law while others are established herein by contractual agreement. Any concerns regarding the matters stated herein should be discussed prior to initiation of treatment. I understand that my records are protected under the applicable state law governing healthcare information that relates to mental health services and under the federal regulations governing Confidentiality of Alcohol and Drug Abuse Patient Records 42 DRF Part 2, and cannot be disclosed without my written consent unless otherwise provided for in state or federal regulations. I also understand that I may revoke this consent at any time except to the extent that action has been taken in reliance on it.
PATIENT AGREEMENTConsent for Treatment • August 10th, 2020
The patient understands that psychotherapy has both benefits and risks. Risks may include experiencing uncomfortable feelings, especially during the first few weeks of treatment because the process of psychotherapy often requires discussing the unpleasant aspects of your life. However, psychotherapy has been shown to have benefits for individuals who undertake it. Therapy often leads to a significant reduction in feelings of distress, increased satisfaction in interpersonal relationships, greater personal awareness and insight, increased skills for managing stress and resolutions to specific problems.
Consent for Treatment/ Health Care AgreementConsent for Treatment • August 30th, 2023
FINANCIAL AGREEMENTConsent for Treatment • June 15th, 2016
Modern Dentistry can offer a better quality of life and peace of mind to those who choose to have dental treatment per- formed. However, there can be risk of complications during and/or after dental treatment. The patient needs to understand there are risks.
Financial Responsibility AgreementConsent for Treatment • July 15th, 2024
Street Address: City: State: Zip Code: By signing this consent form, I give my permission for Clayton S. Hall, D.O. and Associates, LLC (hereinafter “Hall & Associates”) to provide me with evaluation and treatment.
Consent for TreatmentConsent for Treatment • September 26th, 2022
Please read the following information carefully. After you have read this Consent and Agreement, please sign your name below to accept the terms of this agreement.
Consent for TreatmentConsent for Treatment • January 30th, 2014
PATIENT INFORMATION AND CONSENT FOR TREATMENTConsent for Treatment • August 11th, 2020
This document (the Agreement) contains important information about my professional services and business policies. It also contains summary information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights with regard to the use and disclosure of your Protected Health Information (PHI) used for the purpose of treatment, payment, and health care operations. HIPAA requires that I provide you with a Notice of Privacy Practices (the Notice) for use and disclosure of PHI for treatment, payment and health care operations. The Notice, which is attached to this Agreement, explains HIPAA and its application to your personal health information in greater detail. The law requires that I obtain your signature acknowledging that I have provided you with this information. Although these documents are long and sometimes complex, it is very important that you read them carefully. We can discuss any questions you have a
