Health Care Consent

Health Care Consent (Page 2 of 7)

Please fill out the Emergency Medical Consent Form below. Please choose "consent" or "non-consent" before submitting the form. Thank you.

* Indicates required field

Name *

First

Last

Name of Parent or Guardian (if Client is a Minor) *

First

Last

Phone Number *

Email *

Emergency Contact (1st) *

Relationship to Client *

Phone Number *

Emergency Contact (2nd) *

Relationship to Client *

Phone Number *

Patient's Primary Care Physician *

Phone Number *

Preferred Medical Facility *

Medical Consent: The undersigned hereby grants to any Stable Transformation LLC affiliate/employee/intern/volunteer the authority to receive information pertaining to the emergency health care of the client named below and to make emergency health care decisions with respect to the client if the undersigned is unavailable to obtain such information or make such decisions.

I Consent to Medical Treatment *

Yes

Medical Non-Consent: If the undersigned does NOT desire to grant any Stable Transformation, LLC affiliate/employee/intern/volunteer information or to make health care decisions for the client if the undersigned is unavailable, please click "no" in the box below and state the procedures to be followed if the client becomes ill or is involved in an accident and the undersigned is unavailable.

I DO NOT CONSENT to any Stable Transformation, LLC, affiliate/employee/intern/volunteer obtaining health care information or making emergency health care decisions concerning the client.

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions.

I Do NOT Consent to Medical Treatment *

Non-Consent

Name (ESignature) *

Name of Parent or Guardian (If Client is a Minor) *

Date (00/00/00) *

By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual signature on this Agreement. By selecting "I Accept" you consent to be legally bound by this Agreement's terms and conditions.

I Accept