CONSENT FOR TREATMENT

CONSENT FOR TREATMENT

Belle Mead Physical Therapy
Patient Name:
The diagnosis, recommended treatment, benefits, risks, alternatives, and my prognosis were explained to me and my questions were satisfactorily answered.
Signature of Patient

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Signature of Witness

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Date

Month Day Year
Date
- www.bellemeadpt.com • Office: 908-281-6515 • Fax: 908-281-6269
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