Combined Consent

Section I – Consumer Handbook

I have received the Consumer Handbook. I was given time to ask questions and I understand the answers that were given to me.

Section II – Emergencies After Hours

I have been provided with a list of Recommendations for Emergencies After Hours

Section III – Consent to Treatment

I consent to treatment taking place at the following location(s)

Section IV – Coordination of Care

Please Select One

Section V – Financial Responsibility

I understand that I must disclose all insurance coverage. if failure to disclose results ia a denied claim, I will be financially responsible for it. Information on this page has been explained to me. I understand that i may revoke this consent at any time, except for action that has already been taken. a copy of this form shall be as valid as original for a period of one year from date of signing.

Section VI – Signatures