Consent Form

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
Should be Empty: