Consent to Treat for Nutritional Counsel

Name *

Date Of Birth *

Phone *

Address *

Address Line 1

City

State

Zip Code

Phone

Therapist/Counselor

Phone

Medical Provider

Phone

Additional Provider 2

Phone

Payment Consent *

I agree to the billing policies for Lelia Davis

Billing policies can be read here.

HIPAA Compliance *

I have read and understand the HIPAA Policies for Lelia Davis

HIPAA policy can be read here.

Are you 18 years of age or older? *

Yes
No

Print Name *

Signature of Patient *