Standard Contracts
INFORMED CONSENT, OFFICE POLICIES, & GENERAL INFORMATION AGREEMENT FOR PSYCHOLOGICAL SERVICESInformed Consent Agreement • March 18th, 2020
This form provides you (Patient) with information that is additional to that detailed in the HIPPA Notice of Privacy Practices and it is subject to HIPAA pre-emptive analysis. “Patient”, herein this document refers to the identified patient(s) and/or the identified patient’s parent(s) or legal guardian(s).
Informed Consent Agreement / Contract for ServicesInformed Consent Agreement • October 11th, 2021
Welcome to my practice. I am pleased to have the opportunity to work together. This document contains important information about my professional services and business policies. Please read it carefully and feel fee to ask any questions you may have so that we can discuss them. When you sign this document, it will represent a contractual agreement between us.
INFORMED CONSENT AGREEMENT COUNSELING SERVICESInformed Consent Agreement • January 5th, 2022
This document contains important information about our professional counseling services and business policies. It also contains a summary of information about the Health Insurance Portability and Accountability Act (HIPAA), a federal law that provides privacy protections and patient rights about the use and disclosure of your Protected Health Information (PHI) for the purposes of treatment, payment, and health care operations. Although these documents are long and sometimes complex, it is very important that you understand them. We can discuss any questions you have prior to any therapeutic services being rendered or at any time in the future.
INFORMED CONSENTInformed Consent Agreement • August 8th, 2013
Your doctor has recommended AcceleDent Aura as an accessory to your orthodontic treatment. Although orthodontic treatment can lead to healthy teeth and provide important benefits such as an attractive smile, you should also be aware that orthodontic treatment (including orthodontic treatment enhanced with AcceleDent Aura) has limitations and potential risks that you should consider before undergoing treatment.
Dallas Location:Informed Consent Agreement • April 15th, 2021
This document contains important information about Aspen Counseling Service, PLLC’s policies as well as counseling sessions.
CHILDREN’S SPORTS CAMPS – INFORMED CONSENT AGREEMENTInformed Consent Agreement • February 28th, 2022
Durham College and Ontario Tech, Campus Athletic Management Partners, Campus Fieldhouse, Vaso’s Field, the Governors of the Durham College and Ontario Tech Boards, their officers, directors, agents, contractors, employees, coaches/instructors, trainers, volunteers, students, members and representatives (all hereafter collectively referred to as “the institution”), are not responsible for any participant's death, injury, loss or damage of any kind sustained by any person while registered as a Camp participant of the Campus Summer Sports Camp except to the extent that such injury, loss or damage was caused by the negligence of the institution.
INFORMED CONSENT AGREEMENT FIELD TRIP - MULTI-DAYInformed Consent Agreement • November 16th, 2022
As a condition of participation in field trips lasting overnight or longer, this form must be completed by the parent/ guardian of each student participant.
Informed Consent Agreement for Participation in a Research StudyInformed Consent Agreement • November 1st, 2019
You are being asked to participate in a research study. Before you agree, however, you must be fully informed about the purpose of the study, the procedures to be followed, and any benefits, risks or discomfort that you may experience as a result of your participation. This form presents information about the study so that you may make a fully informed decision regarding your participation.
Protocol #: Title Please include the protocol number and title in the header.Informed Consent Agreement • September 14th, 2022
Please delete all information in red and modify the header. Because there are multiple sections in this document, you need to modify the header for each section (i.e. each informed consent agreement).
INFORMED CONSENTInformed Consent Agreement • September 30th, 2020
I/we, , the counselee/s, referred to as I or counselee, have been informed by Redeemed Christian Counseling & Education, Inc. that Biblical Counseling and spiritual guidance are being provided, that this agreement shall govern the professional relationship between the parties, that any disputes or modifications of agreement shall be negotiated directly between the parties, (if negotiations are not satisfactory, then the parties agree to mediate any differences with a mutually acceptable third-party mediator). In the event of a lawsuit, the counselee/s may assume all the costs of litigation including adjunct costs and fees, and all attorney fees.
INFORMED CONSENT AGREEMENTInformed Consent Agreement • August 18th, 2017
These types of injuries may be minor or serious and may result from ones actions, or the actions or inaction’s of others, or a combination of both.
INFORMED CONSENT, OFFICE POLICIES, & GENERAL INFORMATION AGREEMENT FOR PSYCHOLOGICAL SERVICESInformed Consent Agreement • July 26th, 2019
This form provides you (Patient) with information that is additional to that detailed in the HIPPA Notice of Privacy Practices and it is subject to HIPAA pre-emptive analysis. (Revised January 30, 2013).
Informed Consent Agreement for the Installation of Small Cell Towers in Your Residential CommunityInformed Consent Agreement • October 9th, 2020
Will you grant permission for my telecommunications company to erect small cell towers in your residential community, including, possibly, one tower in front of your home?
Dr. Karin A. Mosk, Psy.D. 134 Holiday Court, Ste. 312Informed Consent Agreement • May 11th, 2022
This document 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 new 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 for use and disclosure of PHI for treatment, payment, and health care operations. The Notice 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. We can discuss any questions you have about the process. When you sign this document, it represents an agreement between us. You may revoke this Agreement in writing at any time. That revocation will be bindi
INFORMED CONSENT AGREEMENTInformed Consent Agreement • September 20th, 2018
⚫ I understand and agree that participation in athletics, extracurricular activities not tied to an academic grade and the ability to purchase a parking pass is a privilege that may be withdrawn for violations of Wadsworth City School District’s policies, guidelines, and handbooks including, but not limited to, the Wadsworth City School District Random Alcohol, Drug and Nicotine Testing Policy.
AGREEMENT TO BE IN A RESEARCH STUDYInformed Consent Agreement • December 4th, 2020
This research study is studying the use of Connected Vehicle Devices ((henceforth referred to as the ‘Study Device’) to determine if they improve vehicle safety, specifically to improve driver awareness and reduce the occurrence and severity of crashes.
Informed Consent Agreement forInformed Consent Agreement • July 17th, 2020
Plymouth State University is looking forward to welcoming students, faculty, and staff back to our campus for in-person instruction. We will need the help, cooperation, and participation of you and every other member of our on-campus community to maintain a reasonably healthy and safe campus environment. While none of us can ensure that the campus will be free from the risk of contracting the novel coronavirus, COVID-19, by working together we can manage and mitigate the risk. We ask you to help reduce the risk of transmission by staying current on information about the virus provided by public health officials and experts. The University has established and implemented public campus-wide protocols designed to limit the spread of COVID-19 on the campus and to help safeguard vulnerable persons on campus, in Plymouth, and in the wider community for the 2020–21 academic year. The protocols are available on the University’s Fall 2020 Opening website and the Dean of Students website. Failur
Informed consent & agreementInformed Consent Agreement • November 12th, 2022
Successful orthodontic treatment is a partnership between the doctor and the patient. The doctor and staff are dedicated to achieving the best possible result for each patient. As a general rule, informed and cooperative patients can achieve positive orthodontic results. While recognizing the benefits of a beautiful healthy smile, you should also be aware that, as with all healing arts, orthodontic treatment has limitations and potential risks. These are seldom serious enough to indicate that you should not have treatment; however, all patients should consider the option of no treatment at all by accepting their present oral condition. You should also ensure that you have discussed all orthodontic alternatives available to you with the doctor prior to beginning treatment.
INFORMED CONSENT AGREEMENT FOR TREATMENT OF INTRACTABLE PAIN WITH NARCOTIC MEDICATIONInformed Consent Agreement • April 6th, 2024
Protocol #: Project Title Please include the protocol number and title of your protocol. Title must match exactly the title used at the beginning of your protocol submission.Informed Consent Agreement • August 15th, 2024
Please delete all information in red and modify the header. Because there are multiple sections in this document, you need to modify the header for each section (i.e. each informed consent agreement). Remember that information in the consent should match what is described in your protocol. Always write your consent as if you are in person addressing the participant directly – use phrases like “you will” and not “participants will.”
ContractInformed Consent Agreement • September 11th, 2008
Parents of students under 18: Please read this form and, if you agree, sign it and return it to Dr. Jeanine Skorinko via Fax (508) 831-5896 or mail to: Dr. Jeanine Skorinko, WPI Dept. of Social Science, 100 Institute Rd., Worcester MA 01609
INFORMED CONSENT AGREEMENTInformed Consent Agreement • August 6th, 2020
We, the UNDERSIGNED hereby acknowledge that certain RISKS OF INJURY are inherent to participation in sports and recreational activities. Including but not limited to: SKATEBOARDING/ IN-LINE SKATING/ SCOOTERING/ ROLLER SKATING/DROP-IN RECREATIONAL ACTIVITIES/ROCKCLIMBING. We consent to
INFORMED CONSENT AGREEMENTInformed Consent Agreement • November 8th, 2021
Informed Consent Agreement Supporting InformationInformed Consent Agreement • September 26th, 2022
Yuan Qiong and REN XUE seek to recognize the root causes of symptoms or disease. Yuan Qiong is a comprehensive system that cultivates life as a whole, addressing the imbalances or blockages of Qi (energy) that contribute to illness and problems in life.
Informed Consent to Travel During the Coronavirus (COVID-19) Pandemic and Agreement to Adhere to Academic Travel Abroad’s Traveler Health & Safety ProtocolsInformed Consent Agreement • June 29th, 2021
You are considering travel during the novel coronavirus (COVID-19) pandemic. COVID-19 is an extremely contagious disease that is spread mainly from person to person through respiratory droplets and particles including airborne and aerosol transmission produced by infected people, including those who may be asymptomatic.
INFORMED CONSENT AGREEMENTInformed Consent Agreement • June 7th, 2021
We hereby consent to allow the student named on the reverse side to undergo urinalysis and/or hair follicle testing for the presence of illicit drugs, alcohol, or banned substances in accordance with Policy and Procedures for Drug Testing of the Clermont Northeastern Schools District.
INFORMED CONSENT AGREEMENTInformed Consent Agreement • October 10th, 2013
Agreement and Informed ConsentInformed Consent Agreement • October 24th, 2022
This document contains important information about my teletherapy services and policies. Please, read it carefully and note any questions you might have so we can discuss them during your first session. Once you sign this consent form, it will constitute an agreement between you and I, Camila Barreto, MA, MFT.
Vermilion Local School District INFORMED CONSENT AGREEMENTInformed Consent Agreement • April 29th, 2015
• I understand and agree that participation in extracurricular activities, special privileges and/or parking on school grounds is a privilege that may be withdrawn for violations of Board Policy 5530.01 - Drug Testing Policy, hereinafter Policy.
Informed Consent AgreementInformed Consent Agreement • October 4th, 2021
The best relationships are those that are built on respect and understanding. My informed consent agreement gives you understanding as to my responsibilities as a therapist/healthcare practitioner and your responsibilities as a client.
Informed Consent AgreementInformed Consent Agreement • March 2nd, 2021
INFORMED CONSENT AGREEMENT – SPORTInformed Consent Agreement • January 16th, 2022
In order for any student to participate in school sports it is a requirement for both the student and a parent/ guardian to complete the following:
ContractInformed Consent Agreement • April 28th, 2015
Please delete all information in red and modify the header. For more information about writing consent documents, please see Consent. Remember that information in the consent should match what is described in your protocol.
Informed Consent AgreementInformed Consent Agreement • October 7th, 2009
This is an Informed Consent Agreement, which identifies risks of participating in a Weber State University event, course or program, and a Waiver and Release for participants.
Informed Consent AgreementInformed Consent Agreement • October 28th, 2020
I, the undersigned, hereby acknowledge that certain RISKS OF INJURY are inherent to participation in sports, exercise, and recreational activities. These types of injuries may be minor or serious and may result from one’s own actions, or the actions or inactions of others, or a combination of both. I also understand that it is my responsibility to become knowledgeable about and how to minimize or prevent the risks associated with the activities I choose to participate in. I understand that there is a very remote possibility (e.g., accident) that I might be exposed to bodily fluids (i.e., blood), which may contain the Hepatitis B agent or HIV virus. Please notify the instructor immediately for instructions in dealing with this situation.
