Singing with Parkinson's Registration Form
Thank you for your interest in joining our Singing with Parkinson's virtual rehearsals! We meet virtually on Tuesdays and Thursdays at 1:00pm EST. Please fill out the following information for our records and to be placed on the email list. 
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Email *
If you are a metro Atlanta resident, and you are interested in an in-person choir option, please indicate below. If you are not an Atlanta area resident, please click "n/a" *
Name
Phone Number
Date of Birth
MM
/
DD
/
YYYY
Address
(this is for new choir member "goodie bag" deliveries and will not be used in any other manner)
Please indicate your shirt size below:
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Work Status
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Musical Background
Parkinson's Symptoms
If you selected speech symptoms, please indicate which ones you have been experiencing:
Do you have any secondary diagnoses (dysarthria, etc)?
Which symptom bothers you the most?
Any additional pertinent information?
Emergency Contact Name
Emergency Contact Relation
Emergency Contact Phone Number
Consent to treat: This must be agreed to since this program is public and grant funded.
This Consent to Treat Agreement is between Perfect Harmony Health, and the patient listed above. I do consent for Perfect Harmony Health to provide me with Music Therapy services. I consent to care and treatment falling under the practice guideline of the American Music Therapy Association (AMTA), the Certification Board for Music Therapists, and the State of Georgia. I acknowledge that there is always a risk of injury with any therapy involving physical activities. This agreement constitutes the entire agreement between the parties regarding the matters contained herein. This agreement may be signed electronically, in counterparts, each of which shall be deemed an original but all of which together shall constitute one and the same instrument. I understand and agree that they are jointly and severally liable to Perfect Harmony Health with regard to all obligations contained within this agreement.
 *
This must be agreed to since this program is public and grant funded.  

I give my permission to be photographed, audio taped, and video taped during my participation in this program. This media may be used by Perfect Harmony Health in perpetuity for education and training purposes as well as marketing and press purposes.
 *
I understand that steady progress toward treatment goals success in any therapeutic experience is only attainable through consistent attendance.
 *
HIPAA: This must be agreed to since this program is public and grant funded.
HIPAA Compliance Patient Consent Form 
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: Protected health information may be disclosed or used for treatment, payment, or healthcare operations. The practice reserves the right to change the privacy policy as allowed by law. The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. The practice may condition receipt of treatment upon execution of this consent.

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