Thomas Park, M.D. & Associates23077 Greenfield Rd. Suite 430Southfield, MI 48075 Phone: (248) 552-0044 Fax: (248) 423-7777
Thomas Park, M.D. & Associates23077 Greenfield Rd. Suite 430Southfield, MI 48075Phone: (248) 552-0044Fax: (248) 423-7777
I understand that as a patient at Thomas Park, M.D., P.C. & Associates, I may receive a range of services. The type and extent of services that will receive will be determined following an initial assessment and thorough discussion with me. The goal of the assessment process is to determine the best course of treatment for me. Typically, treatment is provided over the course of several months.I understand that all information shared with the clinicians at Thomas Park, M.D., P.C. & Associates is confidential and no information will be released without my consent. Consent to release information is through written authorization. Verbal consent for limited release of information may be necessary under special circumstances. I further understand that there are specific and limited exceptions to this confidentiality which include the following:
I understand that a range of professionals provide services at Thomas Park, M.D., P.C. & Associates.
I understand that if receiving medications, while they may provide significant benefits, they may also pose risks. Psychotherapy may elicit uncomfortable thoughts and feelings, or may lead to the recall of troubling memories and may have unwanted side effects.
If have any questions regarding this consent form about services at Thomas Park, M.D. & Associates, I may discuss them with my therapist or physician. I have read and understand the above. I consent to participate in the evaluation and treatment offered to me by Thomas Park, M.D. & Associates. I understand that may stop treatment at any time.
As a patient of Thomas Park, M.D. & Associates, I understand and agree to the following:
I hereby give my consent for Thomas Park, MD & Associates to send text message reminders to my mobile phone (as per the number above These messages will be a reminder of my previously booked appointment date and time, or a notification that I need to reschedule an appointment.Should I not be able to keep an appointment, I will call the office to cancel.All patients have the right to change their minds and have this service stopped. If you no longer wish to receive these text reminders, please notify reception. We cannot accept incoming text messages. If you change your mobile number please inform us so that we can update our records.
If you do not want to receive text message reminders please sign below. Please note, this office is no longer calling patients as a form of appointment reminders. By signing below I understand that I will not receive an appointment reminder.