INFORMED CONSENT FOR PSYCHIATRIC TREATMENT
You're here to fill and submit this document. Before we get started, we just want to make sure you understand that your digital signature is legally binding. Contact us in advance if you have any questions about this process.
This notice is Pursuant to the US Department of Health and Human Services regulatory changes of the Omnibus Rule.
The psychotropic medication(s) prescribed on this date by Dr Alexandru Serghi, M.D.:
Patient First Name *
Patient Last Name *
Email Address
Optional if you would like a copy of this form emailed to you
Patient’s Signature *
Please type your signature below. This digital signature is legally binding.
Today's Date *
MM
/
DD
/
YYYY
Submit
Never submit passwords through Google Forms.
This form was created inside of Nova Neuropsychiatry PLLC. Report Abuse