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Consent for Treatment Form

Consent for Treatment

Please take a moment to fill out the form.

I, 

give my consent for Life Touch Therapy, PLLC to:

(A) provide evaluation, treatment, and consultation, and

(B) disclose any personal health information including:

Check all that apply

for the purpose of treatment, payment, and healthcare operations. 

I understand that I can discontinue this consent at any time. This consent is effective until the date of discharge from services. I fully understand this form and give my consent.

Thanks for submitting!

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