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I CONSENT to services rendered by Certus including evaluations, consultations, diagnostic testing, clinical therapies, and medication management if indicated. Certus health care providers have informed me of the nature of the recommended treatment and have explained to me the benefits and risks, as well as alternative approaches for care.

I understand that patients will have varying success in treatment depending on the severity of their complaints, their capacity for introspective, and their motivation to apply what is learned outside of sessions. I understand that, although Certus health care providers may conclude that certain treatments may help me, there are no guarantees that my condition will improve from treatment.

Certus health care providers may prescribe medications. Not all patients are a good candidate for medication therapy or have success with it. Sometimes a patient may have to try several different medications before they experience an improvement in symptoms. These medications can have significant side effects that I agree to always discuss with Certus and my pharmacist.

I understand that medication treatment could have effects on my brain, body, consciousness, emotions, actions, sleep, memory, judgment, coordination, stamina and sexuality. Many medications require strict adherence to dosage, frequency, close follow-ups and sometimes regular blood tests. This consent indicates my understanding of these responsibilities and risks.

I understand that while Certus health care providers have explained the treatment to me, there may be problems that develop. I understand that it is my responsibility to inform my Certus health care provider if there are any unexpected changes in my condition or if any problems arise relating to my treatment. If an emergency develops, I will call 911 and go to an emergency room.

I had the opportunity to have my questions answered pertaining to treatment. I have also been given an opportunity to decline treatment. My consent for treatment has been given voluntarily.

By signing below, I certify that I have read and understand the terms stated in the Treatment Consent Form and that I give my consent for treatment.

Patient Name*
Guarantor Name
(if different than patient)
Patient signature required. If consenting as Guarantor, include signature below with patient's signature.
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