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PATIENT 10 – 15 YEARS WRITTEN CONSENT FORM 1...

Paediatric Consent PATIENT 10-15 YEARS WRITTEN CONSENT FORM 2 FOR Medical Research Council Acute Myeloid Leukaemia 15 Trial (Trial Reference ISRCTN 17161961) Induction for Non-APL, Courses 1 and 2 (Please circle one)1. Have you

Microsoft Word - 07-30-12 ALERT Cost Report Settlement Consent Form...

Cost Report Settlement Consent Form Addendum PARTNERS: Cahaba is currently sending out final adjustment packages for Linton A. Harris cost reports that have remained open awaiting finalization of Stephen M. Bedsole FFY 2006 –

Microsoft Word - privacy consent form.doc...

Consent Form – Health Practitioner Sample FormThis is a Sample Form to be used as a template for Denturists – Insert Clinic/Practitionername where appropriateThis office will collect, use and disclose information about you for the

Microsoft Word - Survey Consent Form template for MSA and EDU students...

Consent Form for Anonymous SurveysALL GREEN SECTIONS ARE FOR THE STUDENT ONLY AND SHOULD NOTAPPEAR IN THE ACTUAL FORM. This form is intended as an informationaldocument for subjects who are given the opportunity to

12 - HCC Consent Form...

Hope Counseling Center Wake Forest, NC 919-556-1546 CONSENT FORM Our Goal: The purpose of Biblical Counseling is to help you meet the challengesof life in a way that will please and honor the Lord

Microsoft Word - HIPAA Consent Form 2014.docx...

Allergy Asthma & Immunology Relief, P.A. 8810 Blakeney Professional Drive Charlotte, North Carolina 28277 Tel: 704-910-1402 Fax: 704-910-1506 Email: info@aairofcharlotte.com www.aairofcharlotte.comMaeve E. O’Connor, MD, FACAAI, FAAAAJennifer Caicedo, MDLeandra Tonweber, PA-CJoe Giordano, PA-C    

Youth Travel and Photo Consent Form...

Youth  Travel  and  Photo  Consent  Form 11/28/12We/I  give  my  child,  ________________,  permission  to  travel  with  First  Chris>an  Church  Sedalia,  Youth  group  to  Crown  Center,  Ice  Ska>ng,  on  Sunday,  December  2,  2012.We/I  give  permission  for

skate park parent consent form...

GRAND CENTRAL PARKPARENTAL CONSENT FORM AND RELEASEMinor Child’s Name:(y/n)____ I have included a copy of my driver's license____ I have been provided a copy of, read, understand and agree to the Grand Central Park Membership

2009 H1N1 Influenza Vaccine Consent Form for Intramuscular, Injectable...

2009 H1N1 Influenza Vaccine Consent Form -ChildrenSection 1: Information about Child to Receive Vaccine (please print) STUDENT’S NAME (Last) (First) (M.I.) STUDENT’S DATE OF BIRTH month_________ day______ year__________ PARENT/LEGAL GUARDIAN’S NAME (Last) (First) (M.I.)

Microsoft Word - regular activity consent form.doc...

Writing in orange to be changed / adapted.Please note that individual consent forms are required for each off-premise activity youhost (trips, residentials, etc). Also, if holiday clubs etc, are overseen by a different groupor led

Email consent form...

Heritage Hills Family Medicine, P.C. Greenwood Village, Co www.hhfamilymedicine.comAndreas J. Edrich MD HAllyson “Nicci” Kochsmeier PA-C7000 E. Belleview Ave, Suite 100Greenwood Village, Co 80111sPh: 303-792-3333Fax: 303-792-3361 EMAIL CONSENT FORM FOR HERITAGE HILLS FAMILY MEDICINESign

HALLMARK PRODUCT DONATION CONSENT FORM...

Print Form PRODUCT DONATION CONSENT FORM This is to certify thatName of Organizationis an organization described in Internal Revenue Code Section 501(c)(3) and is exempt from FederalIncome Taxation under Code Section 501(a) and is

Lumina Family Care Patient Portal Consent Form...

Lumina Family Care Patient Portal Consent Form October 19, 2013 Revision 3 1   Lumina  Family  Care  |  6780  Indiana  Ave.,  Ste.  110  –  Riverside,  CA  92506  –  Tel:  (951)  682-­‐1622     Purpose

2014-2015 Annual Influenza Vaccine Consent Form.docx...

The MacDuffie School (413) 255-0011 (phone) 66 School Street Granby, MA 01033 (413) 467-1603 (fax) Attn: School Nurse Email: nurse@macduffie.org ANNUAL INFLUENZA VACCINE CONSENT FORM________________________________________________ ______________________________ Student Name Student Date of Birth Annual Influenza

Consent Form for use of Images...

Consent Form for use of Images (photographs, videos, DVDs and digital images)Photographs and/or video recordings of children may be taken whilst they attend the school to celebrate theirachievements and successes and as evidence of their

Microsoft Word - Walk Talk Therapy Consent Form.docx...

WALK/TALK THERAPY CLIENT CONSENT FORM Growth Counseling Services, Inc. Mari A. Lee, LMFT, CSAT Licensed Marriage and Family Therapist - #47920I, _________________________________, have requested walk/talk therapy (i.e. aregular weekly therapy session that takes place

Psychotrophic Medication Consent Form CF 173C 5/10...

Psychotropic Medication Consent Form Children, Adults and Families Foster Care Unit Date of appointment:Section A – Psychotropic medication recommendation: (to be completed by licensed medical professional)Identifying information:Child’s name: Date of birth:Sex: Height: Weight: Male

Informed Consent Form...

Ronald M. Dressler, DDS ⧫ Mercury Free Dental, P.C. ⧫ Carol S. Berman, DDS! ! INFORMED CONSENT FORM! !I,____________________________, give my dentist Dr. Ronald Dressler / Dr. Carol Berman permission to removeserviceable dental amalgam

Microsoft Word - Consent Form - youth.doc...

OFFICE LOCATION | 358 N. Main, Wichita KS 67202 PHONE | 316.978.3843 TOLL FREE IN KS | 800.445.0116 FAX | 316.978.3593 Riley/Pottawatomie County Community Needs Assessment Consent Form Youth SurveyYou are invited to take

Microsoft Word - Consent Form - online.doc...

OFFICE LOCATION | 358 N. Main, Wichita KS 67202 PHONE | 316.978.3843 TOLL FREE IN KS | 800.445.0116 FAX | 316.978.3593 Riley/Pottawatomie County Community Needs Assessment Consent Form Online SurveyPurpose: You are invited to

Parental Consent Form - Gaming Tournament.pub...

Parental Consent Form Players must bring a completed copy of this form to the tournament or forfeit their registration fee and ability to play in the tournament.I acknowledge that Call of Duty: Modern Warfare

Microsoft Word - vasectomy consent form.doc...

Metropolitan Urology Vasectomy Center J. Heller, M.D. A. Kern, M.D. P. Fadden, M.D.Patient Consent Form:The purpose of a vasectomy is sterilization, (the inability to father children).Doctor __________________ has described the procedure, its possible risks

Microsoft Word - Patient Consent Form _HIPPA_.doc...

Dr. J. Michael Fite, M.D.1125 South HendersonFort Worth, TX 76104Patient Name: ___________________________ I hereby authorize employees and agents; including physician and nurse: of this medical office to render routine medical care to the patient indicated

Photo Consent Form...

Canadian  Society  of  Physician  Executives   CONSENT/RELEASE  FORM   Author  Photos/Images    The  purpose  of  this  consent  and  release  form  is  to  request  your  permission  to  publish  electronically  the  enclosed  photo(s)  as  displayed  in

Testimonial Consent Form...

401 South Clairborne Road Timir Bhakta, DC, MS, FASA, CES, PES Ste 202 Olathe, KS 66062 Chiropractic Physician Phone: (913) 397-6900 KS Lic # 01-04981 Fax: (913) 397-7999 www.DrTimDC.com PATIENT TESTIMONIAL CONSENT RELEASEPurpose of

Microsoft Word - Divorced Parent Consent Form...

Dear _____________________,I am in the process of seeking therapy for our child, _____________________, at TheCounseling Center of Nashua. Please complete the following questions, sign below, andmail or fax this form back to the Counseling Center.

CONSENT FORM FOR ELECTIVE ULTRASOUND...

I hereby authorize Sneak Peek, LLC to perform a 2D, 3D, and/or 4D ultrasound on me andmy baby. I elect to have this procedure and I understand that the purpose of thisultrasound is not for

Microsoft Word - Photograph Video and Social Media Consent Form.doc...

Hillsboro Quarterback Club Photograph, Video, & Social Media Consent and Release FormDuring the summer and throughout the school year, the Hillsboro QuarterbackClub may wish to use your child’s photograph and/or film, video tape, or

YDYF Medical Consent Form 2014...

Yorkshire Divisional Youth Fellowship Medical consent formTo be completed in respect of a child under 16 bya parent or by a young person over the age of16.Please ensure this form is fully completed Does

Microsoft Word - H1N1 consent Miami-Dade clinic -...

IM or Intranasal Miami‐Dade County Health Department  2009 H1N1 Influenza Vaccine Consent Form (For Children)   For your child to be eligible to receive the H1N1 Influenza vaccine, you must answer all questions and sign this consent form. Depending on your answers and the availability of the vaccine, your child will receive either the injectable or the intranasal flu vaccine. Please read both vaccine information statements we have provided for  st styou. If this is the 1  time that a child under 10 years of age receives the H1N1 influenza vaccine, then s/he will receive a 2nd dose of the flu vaccine 4 weeks after the 1  dose.  This consent form will cover both flu vaccine doses, if needed.  Section 1: Information about Child to Receive Vaccine (please print) CHILD’S NAME (Last)  (First)  (M.I.)  CHILD’S DATE OF BIRTH    Month_________ Day____...

Raintree Intake & Consent form.indd...

Attachment B1.003A PATIENT INTAKE AND CONSENT FORM Attachment M7.005CInternal Use Only: A/C# Name A/C Type Office#First Name MI Date of Injury/Onset Today’s DateLast Name Date of Birth AgeAddress Sex oM oF Marital Status oS

Microsoft Word - Consent Form 2014-2015...

REQUEST FOR TRANSPORTATIONI the undersigned, __________________________, the parent or legalguardian of (typing your name serves as your signature)____________________________, hereby allow, authorize and consent formy child to ride in the “Dr. Elms’ Orthomobile” provided by ElmsOrthodontics,

Microsoft Word - Consent Form...

Consent for Release of Information DHS Policy #504 I hereby give my consent for a criminal history record check. I understand that this is a preliminary check for employment purposes and that all prior

Patient Consent Form Liposonix ®...

The Liposonix system is an FDA cleared device that uses High Intensity Focused Ultrasound (HIFU) tonon-invasively treat fat tissue beneath the skin in the abdomen and flanks (“love handles”). TheLiposonix system focuses HIFU energy at

Microsoft Word -...

Oris Dental Center INFORMED CONSENT FOR ZOOM! TOOTH WHITENING TREATMENTINTRODUCTIONThis information has been given to me so that I can make an informed decision about having my teeth whitened. I have the rightto ask

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