Guardian's Statement and Consent for Treatment

Patient's Information:

Patient's First Name

Patient's Last Name

Patient's Birthday

Guardian's Information:

Guardian's First Name

Guardian's Last Name

Guardian's Phone no.

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Relationship to Patient

Legal Relationship to Patient

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Guardian's Statement and Consent for treatment

I, the legal guardian to the above mentioned patient, who is seeking treatment with your clinic, via tele psychiatry, agree to the following terms and conditions

I have reviewed and accept terms & condition of Mid-Florida Psychiatry Center's EMAIL use policyCLICK HERE to read...

I accept and agree for a no show of $35- unless I cancel the appointment 24 hours ahead of the actual appointment time.

I have reviewed and accept terms & conditions of Mid-Florida Psychiatry Center's TELEPSYCHIATRY policy CLICK HERE to read...

I do consent for release patient's medical, psychiatric, substance use and other pertinent/sensitive information to/ from with Mid-Florida Psychiatry Center. I further understand that I can revoke this consent at anytime with a written request.

This is a general consent to treat with psychotropic medication, though individual verbal/ written consent may be obtained from patient or guardian, at the time of prescribing medication, changing medication. Read more on general classes of meds, and their side effects CLICK HERE to read...

I have reviewed and accept terms & conditions of Mid-Florida Psychiatry Center's HIPAA Privacy Practices NoticeCLICK HERE to read...

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Vidyasagar Vangala, MD; FAPA