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mobility - progress - passion
Consent to Treat
I acknowledge that I have reviewed and agree to the information about the following:
*
1. I accept the payment policy
2. I accept the medicare benefit policy (if individual is > or = 65 years old)
3. I accept the cancellation/no show policy
4. I accept HIPAA/Privacy Rights
Name
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First Name
Last Name
Date
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DD
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Thank you!