APPLICANT'S HEALTH INFORMANTION








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(If the client refuses to sign this consent for the purpose of treatment, payment and health care operations, the therapist has the right to refuse to give care.)


CLIENT CONSENT: By submitting this client health information and consent form as the client or guardian of said client, I acknowledge that I understand and agree to the therapist / office to use my client health information. I have my physician’s consent to opt for this treatment. I have been given appropriate opportunity to address any questions or request clarification for anything that is unclear to me. I am voluntarily agreeing to pay (said fees) and receive the treatment and services for me (or my child if said child is the client).

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