Care Agreement & Consent For services

Patient/ Client Name(Required)
Name Of Person Completing Form (If not patient)
Consent To Receive Services(Required)
Authorization Of Emergency Services(Required)
Statement of Patient Right & Responsibilities & Notice of Privacy Practices & Privacy Right(Required)
Statement of Patient Right & Responsibilities & Notice of Privacy Practices & Privacy Right(Required)

Patient Rights On Advance Directive

Consent(Required)

Service Options

Choose the type of services you would like to utilize:(Required)

Patient/Client Signature

This form must be signed by the I-CARE, Inc. patient/client unless the patient/client is a minor, incompetent, or physically incapable of signing. I have read and fully understand the content of this Consent Form and hereby agree to and authorize the foregoing provisions. As used in this document, the terms “I’, “me” and “my” refer to and include, in addition to the undersigned, the patient/client named above and others for whom the undersigned is responsible or for whom the undersigned has assumed responsibility in engaging I-CARE, Inc. to provide services to the patient/client.
MM slash DD slash YYYY
Patient/ Client Electronic Signature or Signature Of Authorized Representative(Required)
Electronic signatures are legally valid and hold the same weight as handwritten signatures