Patient Consent/Contract for Treatment:
In agreeing to receive treatment for medications and/or therapy, I acknowledge and agree to the terms outlined in this contract:
Appointment Attendance: I agree to attend all scheduled appointments punctually.
Payment Policy: I agree to adhere to the payment policy outlined by this office, ensuring payments are made via cash, credit card, or certified check.
Conduct: I agree to conduct myself in a courteous manner while in the doctor's office.
Medication Handling: I agree not to sell, share, or mishandle my medication, understanding that such actions may result in termination of my treatment.
Illegal Activities: I agree not to engage in any illegal or disruptive activities in the doctor's office.
Reporting: I understand that any observed or suspected illegal activities will be reported to my doctor's office, potentially leading to termination of my treatment.
Medication Dispensing: I agree that medication/prescriptions will only be provided during regular office visits, with missed visits potentially delaying access to medication.
Medication Responsibility: I agree to keep my medication in a safe, secure place and understand that lost medication will not be replaced.
Medication Sources: I agree not to obtain medications from sources other than my treating physician.
Medication Disclosure: I will inform my physician of all medications I am currently prescribed.
Medication Adherence: I agree to take my medication as instructed by my doctor and consult them before altering dosage.
Therapy Participation: I understand that medication alone is not sufficient treatment and agree to participate in counseling as outlined in my treatment plan.
Substance Abstinence: I agree to abstain from specified addictive substances.
Testing Consent: I consent to random urine samples or testing, as requested by my doctor.
Appointment Communication: I will notify the office in case of appointment changes or cancellations, understanding potential fees for missed appointments.
Insurance Responsibility: I acknowledge that insurance reimbursements are not guaranteed, and I am responsible for any balances owed.
Insurance Updates: I will inform the office of any changes to my insurance policy.
Treatment Compliance: Failure to comply with treatment visits for 90 days may result in termination of treatment.
Practice Termination: If terminated from the practice, I understand I will not be able to reschedule and will be referred to other providers.
Violation Consequences: I understand that violations of this contract may result in termination of treatment.
Consent for Services:
I acknowledge receipt and understanding of the terms outlined in this Consent for Services. If any questions arise, I will contact my Provider for clarification.
Revision-4/14/24 Faisal Rafiq