Medication Assisted Treatment Consent Form
Patient Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Phone Number
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Details
In case of emergency, we will contact the person below:
Emergency Contact Name
First Name
Last Name
Phone Number
Format: (000) 000-0000.
Relationship
Current use
Select all that apply
Fentanyl
Heroin
Cocaine
Methanphetamine
Other
If other what substance
Social Information
Race/ Ethnicity
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native hawaiian or Other Pacific Islander
White
Access to housing
Access to healthy food
Access to transportation
Type of insurance
Employment
Consent and Waiver
I, undersigned, consent to assessment and treatment by McDowell EMS and authorize McDowell EMS to share my information between McDowell County EMS and High Country Community Health. This information will be shared to contact me for the purpose of providing post overdose support and connecting me with other resources. The information that will be provided will include, but may not be limited to, my contact information and information about any hospitalizations or EMS treatment during which I received care for substance use related overdose or complications.
Release........
Signature of the Patient
Date Signed
-
Month
-
Day
Year
Date
Submit
Submit
Should be Empty: