Consent to Treat Form:

I/We hereby give consent to Petal Psychiatry to provide medication management services to myself/my child.

I understand that all information will be kept confidential with the following exceptions:

1. Suspected child abuse;
2. Suspected elder abuse;
3. Suspected intent on the part of the patient to harm himself/herself;
4. Suspected intent on the part of the patient to harm another individual.

I understand that I can revoke treatment at any time with written notice to Petal Psychiatry.

Patient Name:* Electronic Signature:* Relationship (if signing for pediatric patient) Does pediatric patient have an appointed legal guardian outside their biological parents? If so, whom? Date* I agree that my electronic signature is the legal equivalent of my manual signature on this agreement.

Submit