The purpose of this form is to ensure that all safety precautions are taken to provide you (the client) quality care
and optimal outcome of the services provided. The provider is not responsible for any negative outcomes due to withheld information. This information will remain on file for one year and will be stored in accordance with HIPPA guidelines, we will not share your information and it will be kept confidential.
*By signing this form, you (the client) are stating that you have read and understand the above disclaimer and are allowing the provider to perform services requested.