Thomas Park M.D. & Associates - New Patient Forms

Thomas Park, M.D. & Associates
23077 Greenfield Rd. Suite 430
Southfield, MI 48075
Phone: (248) 552-0044
Fax: (248) 423-7777
CONFIDENTIAL
INFORMED CONSENT FOR ASSESSMENT AND TREATMENT
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:
1. 1. When there is risk of imminent danger to myself or another person, the clinician is ethically bound to take necessary steps to prevent such danger.
2. When there is a suspicion that a child or elder is being sexually or physically abused or is at risk of such abuse, the clinician is legally required to take steps to protect the child or elder, and to inform the proper authorities.
3. When a valid court order is issued for medical records, the clinician and the agency are bound by law to comply with such requests.
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.
Patient Full Name*

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Date of Birth*

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Patient Signature*

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Guardian Signature (if applicable)

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Thomas Park, M.D. & Associates
23077 Greenfield Rd. Suite 430
Southfield, MI 48075
Phone: (248) 552-0044
Fax: (248) 423-7777
PAYMENT for SERVICE AGREEMENT
Patient Name*

First NameLast Name
Patient DOB*

MonthDayYear
Date
As a patient of Thomas Park, M.D. & Associates, I understand and agree to the following:
1. Thomas Park, M.D. & Associates staff verify my insurance benefits and eligibility as a courtesy only and this is not a guarantee of coverage or payment.
2. It is my responsibility to know my individual insurance benefits.
3. I understand that even if the insurance company misquotes my benefits, I am still responsible for paying the appropriate amount for the services I receive.
4. Thomas Park, M.D. & Associates charges a no-show/late cancelation fee of $50 if I do not give 24 hours notice if I have to cancel or change my appointment time. Arrival of 15 minutes or later is considered a no-show.
5. No-show/late cancelation fees are not refundable by my insurance company and I am solely responsible for this payment.
6. All session fees are collected prior to the start of each session.
Patient Signature*

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Date Signed*

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Thomas Park, M.D. & Associates
23077 Greenfield Rd. Suite 430
Southfield, MI 48075
Phone: (248) 552-0044
Fax: (248) 423-7777
CLIENT TEXT MESSAGE CONSENT FORM
Mobile Number (XXX) XXX-XXXX*
Patient Name*

First NameLast Name
Patient Date of Birth*

MonthDayYear
Date
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.
Client/Guardian Signature

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Date

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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.
Client/Guardian Signature

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