Patient Forms Consent to Treatment PATIENT INFORMATION First and Last Name* Date of Birth*===================================CONSENT TO TREATMENTI authorize Shanthi Trettin, M.D., M.A. of Women’s Psychiatric Healthcare, LLC (WPH) to provide therapy and medications as necessary and as agreed upon by me. I understand that it is the responsibility of Dr. Trettin to explain diagnostic tests and available treatment options, including the most common side effects, risks, and benefits. I also understand that the practice of medicine is not an exact science and that no guarantees have been made to me as to the results of my evaluation and treatment. Consent to Treatment Signature* Date signed for consent to treatment*===================================AUTHORIZATION FOR RELEASE OF INFORMATIONI authorize WPH to communicate with/release my medical records to (via telephone, letter, or fax) the following persons (e.g., Primary Care Physician, family members): 1. Name of person and your relationship to that person* 2. Name of person and your relationship to that person 3. Name of person and your relationship to that person 4. Name of person and your relationship to that person Authorization for Release of Information Signature* Date signed for authorization to release*===================================EMAIL CONSENTI agree that it is my choice to use email to contact Dr. Trettin. I understand that email communication is a convenience and not appropriate for emergencies or time-sensitive issues.I am aware that WPH email communications are encrypted and password protected. It is, however, not possible to guarantee the privacy of email messages. Employers generally have the right to access any email received or sent by a person at work.I understand that, at the discretion of Dr. Trettin, my email communications may need to be replaced either by phone calls or office visits. I hold harmless WPH for information loss due to technical failures of equipment. Email Consent Signature * Date signed for email consent*===================================PRACTICE POLICIESI reviewed practice policies outlined on the website. I was given the opportunity to ask questions and my questions were answered. Practice Policies Signature* Practice Policies Date Signed* reCAPTCHASubmitReset
