Form: Consent to Treat

Please complete this form online and click send at the bottom.

I hereby request and consent to the treatment plan as explained to me for my medical symptoms, complaints, illness.

I hereby request and consent to the performance of medical care for me (or for the patient named below, for whom I am legally responsible) by the clinicians who now or in the future work at the clinic or office listed above or any other office or clinic.

I understand and am informed that, in the practice of medicine, there are some risks to treatment. I do not expect the clinician to be able to anticipate and explain all risks and complications. I wish to rely upon the clinician to exercise judgment during the course of the treatments, which the clinician feels at the time, based upon the facts then known to him or her, is in my best interest.

I have read, or have had read to me, the above consent. By signing below I agree to the above-named procedures. I intend this consent form to cover the entire course of treatment for my present condition and for any future condition(s) for which I seek treatment.

All procedures and prescriptions will be covered by this consent and will be in effect until the patient revokes the consent in writing to this practice.

I understand that results are not guaranteed.

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Patient Name:

Email:

Phone:

E-Signature of Patient or Guardian:

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