PATIENT AGREEMENTPatient Agreement • August 26th, 2024 • Rhode Island
This is an agreement between DIRECT DOCTORS, Inc., a Rhode Island Professional Corporation (Direct Doctors), and Dr. Ashley Lakin DO / Dr. James Hedde DO / Dr. Mark Turshen DO / Dr. Lauren Hedde DO / Dr. Sara Delaporta MD (CIRCLE ONE) (Physician) in his/her capacity as agent of Direct Doctors, and you, (Patient).
PATIENT AGREEMENT MATTHEW HADEN MD, LLC d/b/a MODERN MOBILE MEDICINEPatient Agreement • December 6th, 2022 • Virginia
This is an Agreement entered into on , 20 , between Matthew Haden MD, LLC d/b/a Modern Mobile Medicine, an Arizona Limited Liability Company (Modern Mobile Medicine, Us or We), and (Patient or You).
INTEGRATE INTERNAL MEDICINE FOUNDATIONAL HEALTH - PATIENT AGREEMENTPatient Agreement • February 20th, 2023 • Idaho
This Patient Agreement (Agreement) is between Integrate Internal Medicine, P.C. (the Practice, Us or We), and (Patient, Member or You).
AULIKE HEALTH PARTNERS LLC PATIENT AGREEMENTPatient Agreement • February 7th, 2022
I, , the parent/guardian of the above patient(s) have read and understand the following documents that were provided to me to review:
UNIVERSITY HEALTH CENTER PATIENT AGREEMENTPatient Agreement • June 22nd, 2023
I, , hereby authorize University Health Center (UHC), their employees and consultants to perform diagnostic and treatment procedures which, in their judgement, may become necessary while I am a patient at the University of Georgia. I understand that I will be involved and engaged in my care and treatment. I understand that UHC utilizes the services of Physician Assistants, and I have a right to consult with a physician prior to receiving a prescription drug or device order. If I require specialized and/or emergency care, I will be referred to the appropriate medical facility or professional. I understand that a person listed as my emergency contact will be notified if considered necessary by the professional staff of University of Georgia.
PATIENT AGREEMENTS AND ACKNOWLEDGEMENTPatient Agreement • April 4th, 2022
Kiamichi Family Medical Center, Inc. (KFMC) and its personnel are hereby authorized to administer any medical, diagnostic or therapeutic treatment as may be deemed necessary or advisable. I represent to KFMC that I have the right to consent or refuse consent, to any proposed procedure or therapeutic course, absent emergency or extraordinary circumstances.
PATIENT AGREEMENT NOSTALGIA FAMILY MEDICINE P.A.Patient Agreement • May 31st, 2024 • Florida
This is an Agreement between NOSTALGIA FAMILY MEDICINE P.A.., a Florida professional corporation, located at 771 Ciara Creek Cove, Longwood, FL 32750 (NOSTALGIA), Brandon S. Fletcher, M.D. (Physician) in his capacity as an agent of NOSTALGIA, and you, (Patient).
PATIENT AGREEMENTPatient Agreement • October 6th, 2020 • Arizona
The Practice, located at 9300 E Raintree Drive, Suite 2, Scottsdale, Arizona 85260, provides ongoing primary care services to its patients/members in a direct primary care practice model (DPC). In exchange for certain periodic fees the Practice agrees to provide the Patient with certain Services under the terms and conditions contained in this Agreement.
Patient AgreementPatient Agreement • April 8th, 2021 • Washington
This is an Agreement between Cornerstone Family Medicine, PLLC, located at 326 North Market Street, Washington, NC, (Cornerstone), and J. Wesley Earley, MD (Physician) in his capacity as an agent of Cornerstone, and you,
PATIENT AGREEMENTPatient Agreement • October 5th, 2023 • Indiana
The Practice, located at 1501 S. Court Street, Suite 206, Crown Point, Indiana 46307, provides ongoing primary care services to its patients/members in a direct primary care practice model (DPC). In exchange for certain periodic fees the Practice agrees to provide the Patient with certain Services under the terms and conditions contained in this Agreement.
CPM PATIENT AGREEMENT FORMPatient Agreement • January 12th, 2024
ContractPatient Agreement • April 16th, 2004
PATIENT’S AGREEMENT WITH HOSPITAL IN RELATION TO A HOME OTHER THAN HIS OWN 1. NAME OF VA STATION 2. ADDRESS 3. TELEPHONE NO. 4. NAME OF VETERAN 5. SOCIAL SECURITY NO. 6. CLAIM NO. 7. AGREE TO PAY MONTHLY 8. NAME OF PAYEE 9. ADDRESS 10. TELEPHONE 11. NAME OF SOCIAL WORKER AGREEMENT: I agree to pay monthly the amount specified in Item No. 7 to the Payee named in Item No. 8 for room, board, laundry, and attention to my welfare. I further agree to discuss any matter of concern to me that arises during the course of this agreement with the Payee and with the Social Worker named above before I make any change in this agreement. 12. SIGNATURE OF VETERAN 13. DATE 14. SIGNATURE OF SOCIAL WORKER (WITNESS) 15. DATE
PATIENT AGREEMENTPatient Agreement • November 1st, 2023 • Texas
provides ongoing primary care medicine to its Members in a direct pay, membership model (DPC). In exchange for certain periodic fees, the Practice agrees to provide You with the Services described in this Agreement under the terms and conditions contained within.
PATIENT AGREEMENT Thrive Life Center PLLCPatient Agreement • October 7th, 2021 • Arizona
This is an Agreement entered into on , 20 , between Thrive Life Center, an Arizona Professional Limited Liability Company (Practice, Us or We), and
Patient AgreementPatient Agreement • February 17th, 2021
PATIENT AGREEMENTPatient Agreement • December 31st, 2019 • Florida
This agreement (this “Agreement”) between MEGAN WEIGEL, DNP, L.L.C. d/b/a First Coast Integrative Medicine, a Florida professional limited liability corporation (“FCIM”), located at 14215 Spartina Court, Ste 200, Jacksonville, FL, 32224 and you, (the person signing below, referred to as “You”) is effective as of the date of Your signature.
PATIENT AGREEMENTPatient Agreement • January 21st, 2022 • Florida
Thisagreement(this“Agreement”) between MEGANWEIGEL, DNP, L.L.C. d/b/a First Coast Integrative Medicine, a Florida professional limited liability corporation (“FCIM”), located at 14215 Spartina Court, Ste 200, Jacksonville, FL, 32224 and you, (the person signing below, referred to as “You”) is effective as of the date of Your signature.
Patient Agreement Form — Treatment Agreement for Chronic OpioidsPatient Agreement • March 7th, 2018
We want to ensure that patients and caregivers have clear communication and safe, effective procedures when patients use opioids.
PATIENT AGREEMENTPatient Agreement • January 18th, 2021 • Texas
This is an Agreement entered into on , 20 , between Rockwall’s Gem MD, a Texas Professional Limited Liability Company (Rockwall’s Gem MD, Us or We), and
PATIENT AGREEMENTPatient Agreement • May 18th, 2021 • Tennessee
By your signature, you acknowledge that you are voluntarily becoming a patient of LifeMed Clinic. You also acknowledge this is a Membership Agreement between Lifestyle Medical Ministry, also known as LifeMed Clinic, a Tennessee 501c3 non-profit (Clinic, Us or We), and you (Patient or You).
ABBEY FIELD MEDICAL CENTREPatient Agreement • September 20th, 2019
PATIENT AGREEMENTPatient Agreement • October 19th, 2023
Patient AgreementPatient Agreement • December 30th, 2023 • Arizona
The Practice, located at 5950 S COOPER RD STE 1 CHANDLER AZ, 85249 provides ongoing primary care medicine to its Members in a direct pay, membership model (DPC). In exchange for certain periodic fees, the Practice agrees to provide You with the Services described in this Agreement under the terms and conditions contained within.
PATIENT AGREEMENTPatient Agreement • March 20th, 2017 • South Carolina
This is an Agreement entered into on , 20 , between Verity Primary Medicine & Lifestyle, a South Carolina Limited Liability Company (Clinic, Us or We), and
PATIENT AGREEMENT FORMPatient Agreement • March 17th, 2021
PATIENT AGREEMENTPatient Agreement • October 27th, 2021
This direct primary care agreement is made between EHL Psychiatry LLC dba DreamCloud Psychiatry (“DreamCloud”), a Florida limited liability corporation, and you (“You” or “Patient”). DreamCloud agrees to provide Patient with Medical Services listed in this agreement in exchange for certain fees paid by you according to the terms and conditions described below.
Dry Needling • Vertigo • Spine & Sports Rehabilitation • Pediatrics • Pelvic Health • And more!Patient Agreement • August 21st, 2024
necessary for my diagnosis. I understand that my physical therapy care and treatment may be provided by a physical therapist or physical therapy assistant. I am aware that there are certain risks involved with a physical therapy program. Every effort is made to minimize my risk by continuous assessment of my condition throughout my therapy. I will inform my therapist of any changes in my medical condition, or medications, as they may necessitate change in my therapy program. I will stop any
Patient AgreementPatient Agreement • January 23rd, 2024 • Michigan
This Agreement is between Citadel Health Center, PLLC (the Practice, Us, Our or We), and the person acknowledging this consent electronically and any family members they are enrolling (Patient, Member, They or You).
PATIENT AGREEMENTPatient Agreement • September 22nd, 2021
We are required by federal and state laws to maintain the privacy of your child’s ‘Protected Health Information’, PHI. Your signature below indicates you have received a copy of the ‘Notice of Privacy Practices and Your Rights”, which describes how health care information about your child may be collected, used and disclosed for purposes of treatment or payment or for other specified purposes that are permitted and required by law. This notice also details how you may access this information.
UNIVERSITY HEALTH CENTER PATIENT AGREEMENTPatient Agreement • November 29th, 2018
I, , hereby authorize University Health Center (UHC), their employees and consultant to perform diagnostic and treatment procedures which, in their judgement, may become necessary while at the University of Georgia. I understand that I will be involved and engaged in my care and treatment. I understand that UHC utilizes the services of Physician Assistants, and I have a right to consult with a physician prior to receiving a prescription drug or device order. If I require specialized and/or emergency care, I will be referred to the appropriate medical facility or professional. I understand that a person listed as my emergency contact will be notified if considered necessary by the professional staff of University of Georgia.
Patient AgreementPatient Agreement • May 2nd, 2012
Dr. REP: Date of Surgery: Procedure: UPIN# Primary Ins. Co: Phone: Address: City: State: Zip: ID/Policy#: Group#: Insured: Relationship to Insured: q Self q Spouse q Child Patient: DOB: SS#: Address: City: State: Zip: Secondary Ins. Co: Phone: Address: City: State: Zip: ID/Policy#: Group#: Insured:Relationship to Insured: q Self q Spouse q ChildClaim#(W/C): DOI: Adjuster: Home Phone: Cell Phone: WC PATIENTS ONLY Employer Name: Address: City: State: Zip: Office Phone: Delivery Date: Rented From: to Stop charge date 7 day minimum rental. Overnight rental is considered as a full day.$ per day. CPM Model: Serial#: Thermotek Model: Serial#: Sale Items (Subject to applicable sales tax):q Iceman qContrast q TSLO Back Brace qCompression Therapy (Nano) q CPM Shoulder qShldr/Knee/Back/Ankle Cold Pad q LSO Back Brace qCPM Soft Goods qCPM Knee qBack Wrap q Cervical/Vista Collar q OTS Knee Braces qCPM OtherqShldr/Knee/Back/Ankle Sterile q TENS/E-STIM qCustom Knee Brace q qPain Control Device q
Patient AgreementPatient Agreement • January 26th, 2022 • Hawaii
This agreement is between Deborah Ardolf, ND whose trade name is Dr. Ardolf & Associates, LLC. (hereinafter, “Physician” or “Dr. Ardolf & Assoc”), whose principal medical office is 54-2504 Kynnersley Rd., Kapaau, HI 96755 and you , whose mailing address is , and e-mail address is (the “Patient”).
PATIENT AGREEMENTPatient Agreement • March 29th, 2022
•I acknowledge and understand that the person listed below is voluntarily becoming a Member of The Doc Shoppe, PLLC and that this agreement is non-transferable.
Welcome to Psychiatry of TexasPatient Agreement • May 2nd, 2023
Thank you for choosing us as your psychiatric care provider. Psychiatry of Texas's dedicated providers and staff are committed to ensuring that each patient receives high quality psychiatry services. This Patient Agreement establishes guidelines for your participation in treatment with us. Please read the entire Agreement and if you have any questions, please ask us.
PATIENT AGREEMENTPatient Agreement • November 27th, 2020
PERMISSION FOR EVALUATION AND TREATMENT: I hereby give permission to the professional staff of Pemi-Baker Community Health to perform any test(s) and give any treatment(s), deemed appropriate by the professional(s)
