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INFORMED CONSENT & HIPAA NOTICE
Michael G. Conner, Psy.D Patient Name(s): _____________________________________________________ _________YOUR SIGNATURE BELOW SERVES AS AN ACKNOWLEDGEMENT THAT YOU WERE RECIEVED OR WE OFFERED AN INFORMED CONSENT FORM. You also acknowledge that we discussed this information verbally and you were given an opportunity to ask questions in order to understand your rights and responsibilities as a patient/client. Please sign your name below that you were provided a copy of our Informed Consent & HIPAA Notice. First Person Signature: __________________________________________________ Name: _____________________________________________________ Date: ________________________ Second Person Name: _____________________________________________________ Signature: __________________________________________________ Date: ________________________ IF APPROPRIATE (if you are the parent of a minor, a guardian or the responsible person) Authorizing Person: ________________________________________________ Authorizing Signature: ________________________________________________ |