Consent Form
All consents given below are valid for one year from the commencement of treatment and must be renewed annually. You have the right to rescind your consent to release your personal information at any time - please give written notice of your desire to do so.
*
Primary Care Physician
Please fill in the below information for your primary care physician.
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Therapist
Please fill in the below information for your therapist.
Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
example@example.com
Emergency Contact
I give limited permission for disclosure to my emergency contact to be used only in case of life threatening emergency.
Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Relationship to Patient
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
*
example@example.com
Signature of Patient
*
Clear
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: