Consent to Treat I,* First Last (patient name) give permission for CompServ Health to give me medical treatmentPhone*Consent to receiving texts and emails*I consent to receiving texts and emails for reminders of appointments, groups, and drug testing.2. I allow Restore Health KY to file for insurance benefits to pay for the care I receive. I understand that: Restore Health KY will have to send my medical record information to my insurance company. I must pay my share of the costs. I must pay for the cost of these services if my insurance does not pay or I do not have insurance. 3. I understand: I have the right to refuse any procedure or treatment. I have the right to discuss all medical treatments with my clinician. Patient’s Signature*Date* Date Format: MM slash DD slash YYYY Parent or Guardian Signature (for children under 18)Date* Date Format: MM slash DD slash YYYY Print name* First Last NumberPhonePost Custom Field