Family and Patients
Please take a moment to fill out the form.
give my consent for Life Touch Therapy, PLLC to:
(A) provide evaluation, treatment, and consultation, and
(B) disclose any personal health information including:
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!