Consent to Treat


LEARNING SOLUTIONS
2 Main Street
Florence, MA 01062-3500
(413) 584-0265 ∙ Fax (413) 584-2031

learningsolutions@learningsolutionsls.com

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.

 

 

 

 

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Signature Certificate
Document name: Consent to Treat
lock iconUnique Document ID: 56a1d20b85ada6159397ef61f5a675f180244c5b
TimestampAudit
August 13, 2020 8:28 am EDTConsent to Treat Uploaded by Leslie Roberts - leslie@learningsolutionsls.com IP 96.39.16.94
October 5, 2020 12:48 pm EDT Document owner leslie@learningsolutionsls.com has handed over this document to lroberts@learningsolutionsls.com 2020-10-05 12:48:32 - 96.39.16.94