Consent to Treat Form

Consent to Treat
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
The undersigned agrees that he/she/they have read and understand the following:*

Notice of Privacy Practices for Protected Health InformationPolicies and Procedures AgreementMedication PolicyFinancial PolicyNo Show PolicyTelehealth TreatmentControlled Substance Contract
Patient Signature*

Clear
Date Signed*

MonthDayYear
Date
Signature of Parent, Legal Guardian or Conservator

Clear
Date of Parent, Legal Guardian or Conservator

MonthDayYear
Date
Printed name of Parent, Legal Guardian or Conservator Relationship to Patient
Consent for Treatment:
The undersigned patient or responsible party (parent, legal guardian, or conservator) consents to, and authorizes, services by Columbia Psychiatry. These services may include medication management, laboratory tests, diagnostic procedures, and other appropriate therapies. He/She/They understands that he/she/they have the right to be informed of and participate in the selection of treatment modalities; if requested, is entitled to a copy of this Consent; and has the right to withdraw this consent at any time. He/she/they understand that if signed consent is not given, Columbia Psychiatry cannot provide services to the patient.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Signature of Parent, Legal Guardian or Conservator

Clear
Date of Parent, Legal Guardian or Conservator

MonthDayYear
Date
Printed name of Parent, Legal Guardian or Conservator Relationship to Patient
Payment Information

Our office expects payment at the time of service and to have a form of payment on file for our records. We will be contacting you for that information.
Once submitted, you will be re-routed back to the comopsych.com website.
Should be Empty:

Consent to Treat

Consent for Treatment:

Payment Information

Once submitted, you will be re-routed back to the comopsych.com website.