INFORMED CONSENT AND AGREEMENTInformed Consent and Agreement • May 9th, 2022
We believe that the therapeutic process can be one of the most challenging and the most rewarding endeavors anyone can take. Those involved in therapy can begin to better understand their own life as well as their relationships with other people. Therapy can provide an opportunity for an individual or a couple to set aside time to focus on the issues prevalent in their lives, and to actively begin to communicate desires, goals, and dreams to one's self as well as to one another.
INFORMED CONSENT AND AGREEMENT FORInformed Consent and Agreement • August 17th, 2023
Your doctor has recommended the U-Aligner system as part of your orthodontic treatment. Although orthodontic treatment can lead to a more attractive and healthier smile, you should also be aware than such treatment has limitations and potential risks that you should consider before commencing your treatment.
INFORMED CONSENT AND AGREEMENTInformed Consent and Agreement • March 11th, 2022
Age (as at time of completing this form) – those under the age of 18 are required to have a parent or guardian view and sign this form:
INFORMED CONSENT AND AGREEMENT REGARDING INVISALIGN® ORTHODONTIC TREATMENTInformed Consent and Agreement • August 1st, 2012
Your doctor has recommended the Invisalign® system for your orthodontic treatment. Although orthodontic treatment can lead to a healthier and more attractive smile, you should also be aware that any orthodontic treatment (including orthodontic treatment with Invisalign aligners) has limitations and potential risks that you should consider before undergoing treatment
PATIENT’S INFORMED CONSENT AND AGREEMENT REGARDING ORTHODONTIC TREATMENTInformed Consent and Agreement • July 12th, 2016
PATIENT’S INFORMED CONSENT AND AGREEMENT REGARDING ORTHODONTIC TREATMENTInformed Consent and Agreement • February 24th, 2011
orthodontist 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 seriously consider the option of no orthodontic treatment at all by accepting their present oral condition. Alternatives to orthodontic treatment vary with the individual’s specific problem, and prosthetic solutions or limited orthodontic treatment may be considerations. You are encouraged to discuss alternatives with the doctor prior to beginning treatment.
INFORMED CONSENT AND AGREEMENT AND RELEASE FORMInformed Consent and Agreement • March 12th, 2020
Thank you for choosing to use the activities, facilities, programs or services of Centennial Place Fitness Centre. We request your understanding and cooperation in maintaining your safety and health by reading and signing the following informed consent and agreement and release form.
INFORMED CONSENT AND AGREEMENT TO THE FOLLOWINGInformed Consent and Agreement • October 18th, 2021
• A representative has explained the type of care and services that Minnesota Hospice may provide during the course of my illness.
INFORMED CONSENT AND AGREEMENT TO HIV TESTINGInformed Consent and Agreement • May 5th, 2020
INFORMED CONSENT AND AGREEMENT TO THE FOLLOWING:Informed Consent and Agreement • December 30th, 2015
• A representative has explained the type of care and services that Suncoast Hospice may provide during the course of my illness.
INFORMED CONSENT AND AGREEMENT FOR PSYCHOTHERAPYInformed Consent and Agreement • July 29th, 2022
Hello and welcome to my practice. My goal is to provide quality mental health services to you. This document contains important information about my professional services and business policies. If you have any questions or concerns, please address them immediately with me.
INFORMED CONSENT AND AGREEMENT AND RELEASE FORMInformed Consent and Agreement • September 14th, 2017
some or all of the activities, facilities, programs and services (hereinafter called “Activities”) offered by Eau Claire Tower Fitness Centre. I assume full responsibility for my health and well being during and after my participation in such Activities and for my choices to use or apply at my own risk any portion of the information or instruction I receive.
INFORMED CONSENT AND AGREEMENT TO USE ELECTRONIC RECORDS AND SIGNATURESInformed Consent and Agreement • April 5th, 2023
Please carefully review this Informed Consent and Agreement to Use Electronic Records and Signatures. If you consent and agree to electronically receive, review and sign the documents in the envelope subject to the terms below, check the “I consent to use Electronic Records and Signatures" box and then click the “Review Document" button below.
INFORMED CONSENT AND AGREEMENT AND RELEASE FORMInformed Consent and Agreement • May 21st, 2013
some or all of the activities, facilities, programs and services (hereinafter called “Activities”) offered by Centennial Place Fitness Centre. I assume full responsibility for my health and well being during and after my participation in such Activities and for my choices to use or apply at my own risk any portion of the information or instruction I receive.
INFORMED CONSENT AND AGREEMENT FOR THERAPYInformed Consent and Agreement • January 9th, 2022
Therapy is a process that works in part because of clearly defined boundaries, along with specified rights and responsibilities held by each party. As a patient in psychotherapy, you have certain rights and responsibilities that are important for you to understand. There are also legal limitations to those rights that you should be aware of. Dr. Federici as a psychologist also has certain rights and responsibilities. Some of those rights and responsibilities are described below, as well some specifics of Dr. Federici’s practice. Since you began therapy, there have been significant statutorily changes, as well as how Dr. Federici wishes to conduct his practice. This updated agreement is intended to replace the general informed consent that was agreed to at the onset of your therapy. Dr. Federici’s objective is to provide you with quality service while staying current with the regulations he must follow. From time to time, Dr. Federici may amend his policies to keep up to date. Dr. Feder
INFORMED CONSENT AND AGREEMENT TO PARTICIPATE IN SCHOOL-BASED BEHAVIORAL HEALTH SERVICESInformed Consent and Agreement • August 6th, 2020
Date of Birth: Social Security Number: I, acknowledge that I am the parent, legal guardian, and or person of legal authority to make medical and educational decisions for the minor student named above, and give my voluntary and informed consent for the staff of to provide
INFORMED CONSENT AND AGREEMENT TO TREATMENTInformed Consent and Agreement • January 26th, 2018
TrioClear™ INFORMED CONSENT AND AGREEMENT FOR THE PATIENTInformed Consent and Agreement • September 25th, 2020
Notice to treating office: This form is to be signed by your TrioClear™ patients prior to treatment and kept for your records and should not be sent to other party.
INFORMED CONSENT AND AGREEMENTInformed Consent and Agreement • February 28th, 2011
We believe that the therapeutic process can be one of the most challenging and the most rewarding endeavors anyone can take. Those involved in therapy can begin to better understand their own life as well as their relationships with other people. Therapy can provide an opportunity for an individual or a couple to set aside time to focus on the issues prevalent in their lives, and to actively begin to communicate desires, goals, and dreams to one's self as well as to one another.
INFORMED CONSENT AND AGREEMENT FOR REIKIInformed Consent and Agreement • January 10th, 2022
REIKI: I have been informed by Willow Holistic Center, LLC that Reiki is used as a technique in treatment for a variety of conditions. I understand that Reiki is a Japanese technique for stress reduction and relaxation that promotes healing of emotions, body, mind, and spirit. Even unconscious patterns of self- defeating behavior may begin to dissolve with regular sessions. Reiki can improve how we cope with difficult times and increases our overall sense of well-being. Reiki is administered by the laying on of hands and transfer of energy for healing purposes.
INFORMED CONSENT AND AGREEMENT TO COUNSELLING SERVICESInformed Consent and Agreement • February 5th, 2021
The Beth Donovan Hospice offers short-term (12 - 15 sessions) grief and bereavement counselling services, at no cost to clients who are seeking support in coping with loss. The grief counselling services are offered in person at the Beth Donovan Hospice, online or over the phone and are provided by a professional mental health counsellor.
Informed Consent and AgreementInformed Consent and Agreement • January 9th, 2020
Informed Consent and Agreement This document is intended to provide important information to you regarding your treatment. Please read the entire document carefully and be sure to ask any questions that you may have regarding its contents. By signing this document, you are agreeing that you understand the content to follow. This documents an agreement between you and Wise Mind Counseling and the services that you will be provided. This agreement contains information regarding Health Insurance Portability and Accountability Act (HIPPA) and a disclosure regarding your protected health information (PHI). Although it can be uncomfortable, it is very important that you ask any questions before signing so that you are comfortable with this agreement.Welcome to Wise Mind Counseling! What is therapy and how does it work? Counseling is a process that may take many forms. The process is individualized and tailored between you and your therapist. In counseling, you will discuss a wide array of is
CLEAR ALIGNER (INVISALIGN®) ORTHODONTIC TREATMENT PATIENT’S INFORMED CONSENT AND AGREEMENTInformed Consent and Agreement • May 19th, 2022
Your doctor has recommended the Clear Aligner (Invisalign®) orthodontic treatment. Although orthodontic treatment can lead to a healthier and more attractive smile, you should also be aware that any orthodontic treatment (including orthodontic treatment with Invisalign aligners) has limitations and potential risks that you should consider before undergoing treatment.
INFORMED CONSENT AND AGREEMENT FOR SURECURE™ PATIENTSInformed Consent and Agreement • June 14th, 2020
Your doctor has recommended the SureCure™ system for your orthodontic treatment. Although orthodontic treatment can lead to a healthier and more attractive smile, you should also be aware that any orthodontic treatment (including orthodontic treatment with SureCure™ aligners) has limitations and potential risks that you should consider before undergoing treatment.
