Patient Consent to Treatment

1. CONSENT TO TREATMENT: I consent to Physical Medicine and Rehabilitation related services at Dr. John’s Best Health, and or Home Health Services provided by Dr. John’s Best Health. In doing so, I understand, acknowledge and affirm that such rehabilitation and related services may involve bodily contact, the prescribing/ administration of medication, the performance of injections and other invasive procedures. 2. TREATMENT OF MINORS: I, as parent/ guardian of a minor receiving treatment here under, do hereby agree and understand that I have been advised to remain on the premises during any such treatment, and waive any claim I may have resulting from failure to do so. 3. LIABILITY: I know and agree that Dr. John’s Best Health LLC is not responsible for loss or damage to personal valuables. 4. WAIVER and RELEASE: I hereby release, discharge and acquit Dr. John’s Best Health LLC, its agents, representatives, affiliates, employees, or assigns, of all liability, claim, demand, damage, cause of action, or loss of any kind arising out of or resulting from my refusal to accept, receive or allow emergency and or medical services, including but not limited to ambulance service Emergency Medical Technician, physician or urgent care services. 5. AUTHORIZATION OF PAYMENT: I consent that I will provide full payment to Dr. John’s Best Health LLC on services provided on that day of service. I certify that all the information provided herein is true and correct. I certify that all the information provided herein is true and correct.

Consent to Treatment Patient/ Guardian Name:

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