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 it by clicking this link: IWAMH-Telehealth Guidelines

Patient's Printed Name: (as it appears on your insurance ID) *

Patient's Date of Birth: (MM/DD/YYYY) *

Date today: *

YYYY

Please select if you agree *

Yes, I agree that I have read and understand the Controlled Substance Agreement.

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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