Speech, Language, and Hearing SciencesConsent to Treat & Financial Agreement Form
PATIENT FULL NAME
First Name
Last Name
DATE OF BIRTH
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Month
-
Day
Year
Date
Thank you for choosing the Department of Speech, Language, and Hearing Sciences at MSJ to provide services for you and your family. By signing this form, you are indicating that:
1) You give consent for the Department of Speech, Language, and Hearing Sciences at MSJ to treat you and/or your family member.
Consent for Screening/Evaluation:
YES
NO
Consent for Individual Sessions:
YES
NO
Consent for Group Sessions:
YES
NO
*Consent for Telehealth Sessions:
*
YES
NO
2) You understand the financial policy of the Department of Speech, Language, and Hearing Sciences.
Financial Policy:
Currently, the Department of Speech, Language, and Hearing Sciences does not charge a fee for individual services or group sessions. All individual and group sessions are provided for free.
Please sign below to acknowledge you have reviewed and understand these policies.
Signature:
Date:
-
Month
-
Day
Year
Date
Relationship to patient:
*A secure platform (Zoom) with privacy protection is used for telehealth sessions
Version 2.0 Updated 8/1/23
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