(pal)pediatricaccess line

Consultative Consent Form (English)
I/we are providing consent for:
Patient's name
to receive Care Coordination / Psychiatric Consultation for:
Condition(s) being addressed
With the following intervention(s):
- Care Coordination
- Psychiatric Consultation
I/we understand the following:
- That I/we have been fully informed that we are NOT entering into a treatment relationship with NV PAL and/or its clinical staff and that consultative services are being provided to assist my primary care clinician.
- That I/we have had the opportunity to have all questions answered to my/our satisfaction.
- That this consent is given voluntarily.
- That I am legally competent and have the authority to provide consent for consultation.
- That I have the right to withdraw my consent for this consult at any time.
- That withdrawing consent for this consult will not prejudice my continued treatment relationship.
*Patient signature:
Date:

MonthDayYear
Date
Parent/legal guardian name:
Date:

MonthDayYear
Date
Parent/legal guardian Signature
Date:

MonthDayYear
Date
Email:
example@example.com
Phone number:
Format: (000) 000-0000.
*If patient is a minor, signature may be required, depending on state law
Should be Empty:

Consultative Consent Form (English)