Consent to Treat
LEARNING SOLUTIONS 2 Main StreetFlorence, MA 01062-3500(413) 584-0265 ∙ Fax (413) 584-2031
This form is an agreement between you and Learning Solutions. By signing this form below you are providing consent for us to provide treatment to and are affirming that you are legally authorized to consent to such treatment.
If you do not sign this consent form, we cannot treat
After you have signed this consent, you have the right to revoke it, in writing received by us, and we will not provide further treatment from that time on, but we may already have provided treatment and cannot change that.
Leave this empty:
Your legal name
Your email address
If you have questions about the contents of this document, you can email the document owner.
Document Name: Consent to Treat
Agree & Sign