Patient Consent Form

I,   First Name*   Last Name*, hereby acknowledge that the information provided on this intake form is accurate and true to the best of my knowledge. I understand that providing this information is essential for creating a personalized treatment plan.

I consent to the collection, use, and disclosure of my personal health information for the purpose of providing care and treatment. I also understand that my health information will be treated with the highest level of confidentiality and in compliance with privacy laws and regulations.

By signing below, I consent to the following:

Treatment Consent:
I consent to receiving medical treatment, including but not limited to, assessments, diagnostic tests, and therapeutic interventions based on the information provided in this intake form. I understand that my healthcare provider will discuss all treatment options with me before proceeding.

Confidentiality:
I understand that my personal health information will be kept confidential, and will only be shared with healthcare professionals involved in my care, unless required by law or requested by me.

Communication Consent:
I consent to receiving communications regarding my treatment plan, results, and progress via phone, email, or other means of communication as necessary. I understand that these communications may include sensitive health information.

Right to Withdraw Consent:
I understand that I have the right to withdraw my consent for treatment at any time and may request further information before making a decision regarding my care.

Informed Decision Making:
I understand that I will be fully informed about any procedures or treatments before they are carried out and will have the opportunity to ask questions regarding their potential risks, benefits, and alternatives.

By signing below, I confirm that I have read and understand the terms outlined in this consent form, and I give my consent for the treatments and evaluations discussed.

Signature*   
Date*