CONSENT TO TREATMENT & RECORD SHARING
Name *
Your Email Address *
Date of Birth *
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Brief Treatment Plan:
Do you agree to discuss the following elements of the Treatment Plan with your RMT *
Please check all that apply:
Required
Do you have concerns for your treatment? *
If you answered yes above, do you agree to discuss your concerns about the Treatment Plan with the Therapist.
Clear selection
Do you agree to alert the RMT immediately if you develop a concern at any time. *
Do you authorize and consent the RMT performing the treatments described to you in the Treatment Plan? *
Do you acknowledge that you may withdraw consent to this treatment at any time, and you agree to tell the RMT immediately if you withdrawal consent.
Clear selection
By checking the following boxes, you are indicating that you acknowledge and understand that: *
Required
I consent to sharing My Patient Record. (In the event you may be working with a Lawyer) *
Do you acknowledge and confirm that there is no guarantee or assurance of results regarding your treatments with the RMT. *
Please Print your Full Name below; *
Date *
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