Consent for Treatment Form

Consent for Treatment

Patient Identification

Patient First Name *

Patient Last Name *

Email Address *

Phone Number *

Date of Birth (DOB)

If the patient is under 18 years of age:

I, the undersigned parent or legal guardian, do hereby consent to the examination, care, and treatment of the patient named above, and assume financial responsibility for all services rendered.

Parent/Guardian Full Name (If patient is a minor)

Relationship to Patient (If patient is a minor)

By signing below, I acknowledge that I have read, understood, and agree to the terms of this Consent for Treatment.

Patient or Legal Guardian Signature

Use your mouse or finger to sign in the box below.

Date Signed

(CID : 18022)

New Patient Enrollment

New Patient Enrollment

Consent for Treatment

Patient Identification

If the patient is under 18 years of age:

By signing below, I acknowledge that I have read, understood, and agree to the terms of this Consent for Treatment.

New Patient Enrollment

New Patient Enrollment

Consent for Treatment

Patient Identification

If the patient is under 18 years of age:

By signing below, I acknowledge that I have read, understood, and agree to the terms of this Consent for Treatment.

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