CONSENT FOR TREATMENT
My professional records are separately maintained and no one else can have access to them without your specific, written permission. The undersigned patient or responsible party (parent, legal guardian or conservator) consents to, and authorizes services, by Maryann Ryan, NPP, services may include psychotherapy, medication therapy, laboratory tests, diagnostic procedures and other appropriate alternative therapies. The undersigned understands that he/she has the right to: 1. Be informed of and participate in the selection of treatment modalities.
2. Receive a copy of this consent.
3. Withdraw this consent at any time.
The undersigned also understands that he/she has the responsibility to:
1. Pay for services, in full, at the time of visit.
2. Abide by the policies of the patient information guidelines as presented at the time of initial visit.
3. Acquire any lab tests or other medical treatments (physical exams or physician referrals) deemed medically necessary in order to maintain a safe and healthy lifestyle.