IWAMH-Clinic Policy and Controlled Substance Agreement Form
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Along with this consent form, you should also review our Telehealth guidelines. By signing this consent, you acknowledge your agreement to adhere to these guidelines. You can read the Telehealth guidelines by clicking this link: http://surl.li/syqvg
Patient's Printed Name: (as it appears on your insurance ID) *
Patient's Date of Birth: (MM/DD/YYYY) *
Date today: *
Please select if you agree *
Patient/Guardian's Full Name: (as it appears on your insurance ID)
Patient/Guardian's Date of Birth: (MM/DD/YYYY)
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