Sweets Collective Wellness - Consent for Care and Service

First and Last Name *

Email *

Date *

The general nature of Sweet’s Collective Wellness services has been explained to me. *

I have participated in the development of, and agree to, the care and service plan. *

The nature of the care and services, the expected benefits, material risks and side effects, alternative courses of actions and likely consequences of not receiving care and services have been explained to me. I have had the opportunity to ask questions and I understand the answers and agree to proceed. *

I understand and appreciate that I may withdraw my consent, in part or in whole, regarding the care and service plan at any time by communicating with Sweet’s Collective Wellness. If I choose to withdraw my consent for any aspect of the care or service, that I will be informed of the risks of doing so by the primary caregiver and that the decision to withdraw my consent for part of the care and services will not affect any remaining care or service. *

I acknowledge my responsibility to provide a safe work environment for the Sweet’s Collective Wellness caregiver or any approved subcontractor personnel while he or she is providing the care and service. *

I consent to the collection, use and disclosure of the client’s personal information, including personal health information and records as it pertains to the Client’s care and service for the purpose of providing and facilitating the Client’s care and service with:

Multidisciplinary team (all of those individuals involved in the Client’s care)

Other

Please Specify

With the exclusion of

Please Specify