Service Consent Form

Service Consent Form
Consumer Name:*

First NameLast Name
Legal Representative Name (if applicable):

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Functional Telephone Number:*
Please enter a valid phone number.
Connext care, LLC is an agency the supports individuals with intellectual and physical disabilities. CC contracts with state of Florida under its APD (Agency for Persons with Disabilities) program.

The above consumer is a recipient of Connext Care, LLC. Our agency is responsible and assists consumers with financial, medical and personal needs.
Consumer Statement

The agency and its employees listed below have my permission to assist me with living independently. My staff is apart of my support team and can speak on my behalf about medical concerns, decisions and medication.
I require my staff to be present at my appointments:*
My staff has my permission to receive and make phone calls concerning my medical health, behavioral health, appointments and medication.*
Consent Start Date:*

MonthDayYear
Date
Consent End Date:*

MonthDayYear
Date
Staff Name:

First NameLast Name
Staff Name:

First NameLast Name
Staff Name:

First NameLast Name
Consumer/Guardian Signature:

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Agency Representative Signature:

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Todays Date:*

MonthDayYear
Date
Should be Empty: