Informed Consent


Informed Consent

Patient Conditions of Treatment and Informed Consent to Treat

This document is a binding agreement (the “Agreement”) between Denali Performance Clinic Services/Denali Performance Clinic and/or (We” “Us”) and the individual patient whose name and signature appears below (“You” “Your”). In consideration of the health care services provided to You by Us at the present and at all times in the future, You agree as follows (Your agreement indicated by checking the box in each section and by signing in the space provided):

I am either the patient or the patient's legally authorized representative consenting to the treatment on the patient's behalf. By signing below, I acknowledge that I have read through the above information, and confirm understanding and compliance.


 

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Signature Certificate
Document name: Informed Consent
lock iconUnique Document ID: d5686aa221a417970d19420da51334c507dac761
Timestamp Audit
July 9, 2019 7:29 am MDTInformed Consent Uploaded by Lisa Strauss - accounts@denalimed.com IP 107.191.0.119
July 10, 2019 8:41 pm MDTCindy Meldrum - cmeldrum@denalimed.com added by Lisa Strauss - accounts@denalimed.com as a CC'd Recipient Ip: 107.191.1.119
July 11, 2019 12:40 pm MDTCindy Meldrum - cmeldrum@denalimed.com added by Lisa Strauss - accounts@denalimed.com as a CC'd Recipient Ip: 107.191.1.119