I {name} voluntarily authorize the rendering of such care, including diagnostic tests, medical treatment and medication, by authorized agents and employees Vital TMS Therapy & Mental Health Services, the medical staff, or their designees, as may in their professional judgment be deemed necessary or
beneficial, I acknowledge that no guarantees have been made as to the effect of such examination or treatment on my condition or the condition of the person for whom I am duly authorized to sign.
I understand that I have the right to make decisions concerning my health care or the health care of the person for whom I am duly authorized to make such decisions, including the right to refuse medical and surgical procedures. I understand that I have the right to be treated with dignity and respect without being discriminated against on the basis of nationality, culture, language, gender, age, incapacity, beliefs, economic status, social status, legal status, sexual orientation, and/or my ability to pay. I have the right to not be sexually or morally abused. I have rights to privacy protection at all times. All of my personal and medical information will be treated with the utmost confidentiality. This confidentiality will not be kept when suspicion of child abuse or negligence exists, when there is a threat to my own physical safety and that of others, and/or when a court demands that this confidentiality be breached.
I understand that my personal chart will be kept confidential. I have the right to ask for my chart and photocopy any information within it, and I understand the costs involved. My chart will not be shared with any other agency unless the law requires. I understand that have the right to be informed if a volunteer or student is the provider of my medical care. Staff members at Vital TMS Therapy & Mental Health Services have the right to choose the provider of my medical care within the agency, considering the availability of providers, the level of medical need, and the time needed to perform required services. I also have the right to ask for a second opinion with respect to my treatment and/or diagnosis. I understand that as part of my treatment, I may be prescribed medication, and it is my responsibility to inform my doctor of any changes, side effects, discontinuation, or other medications or supplements that I may be taking.
I understand that I have the right to participate in the development, and modification of my individual treatment plan, and to dispute any treatment denied by my provider with the exception to those that may arise due to a legal order, I have the right to receive an explanation of all the medications prescribed, including secondary effects if these exist.
I understand that I have the responsibility to provide information about my finances and personal information. I have the right of being completely informed as to payment options. I am willing to pay for the services rendered.
I also understand that I am responsible for participating in treatment agreed upon between my provider and myself. I agree to assist to all of my appointments. In case I am not able to attend an appointment, I agree to notify Vital TMS Therapy & Mental Health Services with at least one business day notice, preferably 48 hours notice. It will be considered a no-show if I miss an appointment and don't notify the Vital TMS Therapy & Mental Health Services. After the second no-show, there will be a $50 fee for each missed appointment. If I do not receive services for a full year at Vital TMS Therapy & Mental Health Services, when I return for an appointment, I understand I will need to complete a new intake with my provider.