Returning Patient Paperwork

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

First NameLast Name
Date of Birth (DOB)*

MonthDayYear
Date
Email address*
example@example.com
Street Address*
City*
State*
Zip Code*
Primary Phone*
Primary Phone Type:*

CellHomeWork
Secondary Phone
Primary Phone Type:

CellHomeWork
Social Security Number*
Marital Status*
Parent/ Guardian Name (If applicable)
Primary Physician's Name*
Primary Physician's Phone Number*
Pharmacy Name*
Pharmacy Phone Number*
Primary Insurance*
Primary Policy Holder Name *
Primary Policy Holder Date of Birth*

MonthDayYear
Date
Secondary Insurance
Second Policy Holder Name
Second Policy Holder Date of Birth

MonthDayYear
Date
Allergies, Select none, or please list:*

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Emergency Contact*
Relationship to Patient*
Emergency Contact Phone Number*

Thomas Park, M.D. & Associates
23077 Greenfield Rd. Suite 430
Southfield, MI 48075
Phone: (248) 552-0044
Fax: (248) 423-7777
INFORMED CONSENT FRO ASSESMENT 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 I 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. 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 I 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 I may stop treatment at any time.
Patient Full Name*
Patient Date of Birth*

MonthDayYear
Date
Patient/Guardian Signature*

Clear
Date*

MonthDayYear

Thomas Park, M.D. & Associates
23077 Greenfield Rd. Suite 430
Southfield, MI 48075
Phone: (248) 552-0044
Fax: (248) 423-7777
CONSENT FOR TREATMENT WITH PSYCHOTROPIC MEDICATION
Patient Full Name*
Patient Date of Birth*

MonthDayYear
Date
Prescriber's Name*
My prescriber is recommending that I be treated with the following medication (s)*
I am a patient at Thomas Park, M.D. & Associates. Before I sign this form, I talked to my doctor. I understand:
- The kind of condition I have.
- The reason why my medication is given to patients with my condition.
- The way the medication may benefit me.
- The most important kinds of problems (risks and discomforts) that the medication can reasonably be expected to cause patients with my condition.
- Other kinds of choices (alternatives for care) if I do not take the medication(s).
- My prescriber has explained to me that there may be other risks if I take the medication. They are believed to be small, are not expected, or are unknown.
- I understand that because it can be dangerous to stop taking a medication too quickly, I may have to continue taking a medication for a given time even after I decide to have it stopped.
- No one has given me a promise or guarantee to what will happen if I take the medication.
- All of my questions about the medication have been answered. I know that I can ask my doctor questions which I think of late, and my doctor will answer them.
- After thinking about all these things, I have decided that I want to take the medication listed at the top of this form.
- I give my consent to receive the medication at the top of this form.
- I also give my consent to my prescriber to change the amount, times, combination, and ways the medication is given as they think best.
- I know that if I agree to receive the medication, and later change my mind, I must tell my doctor.
- I understand that I may withdraw this consent at any time, verbally or written.
- I know that I should tell my doctor immediately if there are any changes in my condition after I begin taking the medication.
Please select one:*

I want to take the medications listedI do NOT want to take the medications listedI want to DISCONTINUE/STOP taking the medications listed
Patient/ Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

RETURNING PATIENT PAPERWORK

INFORMED CONSENT FRO ASSESMENT AND TREATMENT

CONSENT FOR TREATMENT WITH PSYCHOTROPIC MEDICATION