Eclipse Mental Health Services

Patient Name:

Date:

I am an independently practicing professional. I am completely independent in providing you with clinical services and I alone am fully responsible for those services. My professional records are electronically maintained, in accordance with HIPAA and no one else can have access to them without your specific, written permission.

The undersigned patient or responsible party (parent, legal guardian or conservator) consents to, and authorizes services, by Dustin O. Hayes D.O., Total Eclipse DMH, PLLC. These services may include psychotherapy, medication therapy, laboratory tests, diagnostic procedures and other appropriate alternative therapies via telemedicine or face to face.

The undersigned understands that he/she has the right to:

Be informed of and participate in the selection of treatment modalities.
Receive a copy of this consent.
Withdraw this consent at any time.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient:

Date Signed:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Parent, Legal Guardian or Conservator:

Date Signed:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Witness (if appropriate):

Date Signed:

Your information will be encrypted.