CONSENT TO TREAT:
l,
for
myself (or the patient named above), hereby consent to such medical treatment and
diagnostic
procedures as necessary and appropriate for my condition or illness based on the
judgment of
my physician(s), to be performed by the physician(s), physician assistant(s),
nurse(s)
or
health care provider(s). I have had and will continue to have, an opportunity to
discuss
treatment options with my healthcare provider, ask questions regarding such
treatment
options, and understand the options discussed.
PERSONAL
BELONGINGS:
I assume full responsibility for all items of personal property that I have brought
to
Pain
Therapy Associates and hereby release Pain Therapy Associates of all liability in
the
event
of loss or damage to such property.
CANCELLATION POLICY-
24-HOUR
NOTICE MUST BE GIVEN FOR ALL CANCELLATIONS. THERE WILL BE A $75 CHARGE FOR FOLLOW-UP
APPOINTMENTS
AND
A $150 CHARGE FOR PROCEDURES
CANCELLED
IN LESS THAN 24 HOURS.