Eclipse Mental Health Services

CONSENT FOR TREATMENT FORM

Please correct the errors described below.

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.. These services may include psychotherapy, medication
therapy, laboratory tests, diagnostic procedures and other appropriate alternative therapies

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.

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.

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.

Your information will be encrypted.

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