Consent to Treat - Suboxone Treatment | Suboxone Doctor

I,*
First Last
(patient name) give permission for CompServ Health to give me medical treatment
Phone*
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
Number
Phone
Post Custom Field