University of California, San Diego Consent to Act as a Research Subject

MRI Patient Screening and History

Griffin Imaging, LLC 220 Rock Street Griffin, GA 30224 (770) 229-4660 Fax:: (770) 229-4632 Specializing In Open MRI, CT & Ultrasound MRI Patient Screening and History Patient Information Sheet PATIENT

PATIENT REGISTRATION. Street City State Zip WORK INJURY/ ACCIDENT

PATIENT REGISTRATION, Last First M.I. SEX: Male Female DOB: / _/ AGE: MARITAL STATUS: SS#: - - PHYSICIAN: ADDRESS: Street City State Zip (HOME) (WORK) TEL: - - TEL: - _- CELL: - _- EMAIL: PRIMARY INSURANCE:

PATIENT INFORMATION: CONTACT INFORMATION: EMERGENCY CONTACT: EMERGENCY PHONE: RESPONSIBLE PARTY (IF OTHER THAN PATIENT)

PATIENT REGISTRATION PATIENT INFORMATION: NAME:,, (M.I.) ADDRESS:,, (Street) (City) (State) (Zip) SEX: MALE FEMALE DOB: / / AGE: MARITAL STATUS: SS #: / / REFERRING PHYSICIAN: CONTACT INFORMATION: (CELL):

Facility Name: Patient Registration. Name: Address: Home: Work: Mobile: Race: Gender: Marital Status: Emergency Contact Information

Facility Date: MRN/Jacket: Patient Registration Address: Home: Work: Mobile: Email: Date of Birth: Race: Gender: Marital Status: SSN: Employer: Registered Location: Physician: Emergency Contact Information

Are you participating in any other research studies? Yes No

Are you participating in any other research studies? Yes No INTRODUCTION TO RESEARCH STUDIES This study is about healthy aging, lifestyles and frailty. We wish to follow individuals at various settings

RESEARCH CONSENT FORM

Background You are participating in the Framingham Heart Study Generation III. The Framingham Heart Study (FHS) is an observational study to find relationships between risk factors, genetics, heart and

REGISTRATION INFORMATION

REGISTRATION INFORMATION PATIENT INFORMATION (PLEASE USE FULL LEGAL NAME) Last: First: MI: Sex: DOB: SSN# Marital Status: Home Phone: Address: Cell Phone: City: State: Zip: Employer: Work Phone: Emergency

CINCINNATI CHILDREN S HOSPITAL MEDICAL CENTER CONSENT TO PARTICIPATE IN A RESEARCH STUDY

CINCINNATI CHILDREN S HOSPITAL MEDICAL CENTER CONSENT TO PARTICIPATE IN A RESEARCH STUDY STUDY TITLE: The International Diffuse Intrinsic Pontine Glioma (DIPG) Registry and Repository SPONSOR NAME: Maryam

UNIVERSITY OF PENNSYLVANIA HEALTH SYSTEM

Gilead Sciences, Inc. GS-US-248-0123, Amendment 1, 19-JUN-2012 A Long Term Follow-up Registry Study of Subjects Who Did Not Achieve Sustained Virologic Response in Gilead-Sponsored Trials in Subjects with

Efficacy of Tympanostomy Tubes for Children with Recurrent Acute Otitis Media Randomization Phase

CONSENT FOR A CHILD TO BE A SUBJECT IN MEDICAL RESEARCH AND AUTHORIZATION TO PERMIT THE USE AND SHARING OF IDENTIFIABLE MEDICAL INFORMATION FOR RESEARCH PURPOSES TITLE Efficacy of Tympanostomy Tubes for

Main Study Informed Consent Form, Version D (Direct)

Approved For Period: 12/12/2017-12/11/2018 Study #:S14-00946 Version date: November 8, 2017 Page 1 of 8 Main Study Informed Consent Form, Version D (Direct) Title of Study: Principal Investigator: Emergency

Pablo Tebas, M.D. Joseph Quinn, RN, BSN Yan Jiang, RN, BSN, MSN

Gilead Sciences, Inc. / Protocol Number GS-US-380-1489 Page 1 of 9 PARTNER PREGNANCY FOLLOW UP CONSENT FORM Sponsor / Study Title: Protocol Number: Principal Investigator: (Study Doctor) Gilead Sciences,

HS# 2012-8680 University of California Permission to Use Personal Health Information for Research Study Title (or IRB Approval Number if study title may breach subject s privacy): Echocardiogram Screening

INFORMED CONSENT DOCUMENT. Project Title: The Contraceptive Choice Center: an innovative health services delivery and payment model

INFORMED CONSENT DOCUMENT Project Title: The Contraceptive Choice Center: an innovative health services delivery and payment model Principal Investigator: Research Team Contact: Tessa Madden Linda Buchanan

HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA CONSENT TO PARTICIPATE IN A RESEARCH STUDY AND RESEARCH SUBJECT HIPAA AUTHORIZATION

HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA CONSENT TO PARTICIPATE IN A RESEARCH STUDY AND RESEARCH SUBJECT HIPAA AUTHORIZATION Protocol Title: Imaging and Inflammatory Biomarkers in Anti-Retroviral Neuro-Intensification

University of South Florida

Office use only: Sent by: website Date: University of South Florida 4001 E. Fletcher Avenue Tampa, FL 33613 Please mail to the address above or Fax to (813) 974-4251 New Patient Appointment Request Thank

UBC MRI Research Centre

THE UNIVERSITY OF BRITISH COLUMBIA UBC MRI Research Centre 3T Facility SAFETY POLICY July 2, 2008 The following document contains important safety information with respect to the 3T Facility at the UBC

Advance Directive. including Power of Attorney for Health Care

Advance Directive including Power of Attorney for Health Care Overview This is a legal document, developed to meet the legal requirements for Wisconsin. This document provides a way for a person to create

Last Name: First Name: Advance Directive including Power of Attorney for Health Care

Patient Medical Record Number: Or Label Advance Directive including Power of Attorney for Health Care Overview This legal document meets the requirements for Wisconsin.* It lets you Name another person

RESEARCH SUBJECT INFORMED CONSENT AND HIPAA AUTHORIZATION FORM

RESEARCH SUBJECT INFORMED CONSENT AND HIPAA AUTHORIZATION FORM Protocol Title: Gut Microbiome and p-inulin in CKD - TarGut CKD study Principal Investigator: Dominic S.C. Raj, MD Medical Faculty Associates

University of Pittsburgh

University of Pittsburgh Department of Critical Care Medicine Consent to Participate in a Research Study of a Monitor Study Name: Research Directors: Augmented multimodal neurologic monitoring in high

Last Name: First Name: Advance Directive. including Power of Attorney for Health Care

Overview Patient Medical Record Number: Or Label Advance Directive including Power of Attorney for Health Care This legal document meets the requirements for Wisconsin.* It lets you Name another person

TTNI Safety Policy. d. Controlled Drugs: Controlled substances are NOT allowed at this time.

TTNI Safety Policy 1. Regulatory Requirements for the Conduct of Human Studies a. IRB and TTNI Approval: The TTNI Protocol Review Committee and the Texas Tech University Institutional Review Board (IRB)

Signature (Patient or Legal Guardian): Date:

X-Ray Patient Information: [ ] Male [ ] Female Patient Name: Date of Birth: / / SS#: Mailing Address: City: State: Zip: Phone # s: (Home) (Work) (Cell) Referring Physician: Phone #: /Fax#: Additional Physician:

Dr. Kristin Heins, ND Thrive Natural Family Health 110 Eglinton Avenue East, Suite 502 Toronto, Ontario M4P 2Y1 Telephone: (647)

Psychotherapy Client Information Today's date: A. Identification Your name: Date of birth: Age: Your nicknames/previous/maiden/aliases: Sex: [ ]Male [ ]Female Gender: Title: [ ]Mr. [ ]Mrs. [ ]Miss [ ]Ms

SAINT AGNES MEDICAL CENTER CLINICAL RESEARCH CENTER Fresno, California. STANDARD OPERATING PROCEDURES Institutional Review Board

SAINT AGNES MEDICAL CENTER CLINICAL RESEARCH CENTER Fresno, California STANDARD OPERATING PROCEDURES Institutional Review Board Date Effective: April 26, 2001 Index No. R 1217 Date Last Revised: 0 Date

Shadowing/Observer Application

Shadowing/Observer Application PLEASE READ AND FOLLOW THESE INSTRUCTIONS: Complete and sign ALL forms in this packet and EMAIL to learningresources@gwinnettmedicalcenter.org. All shadowing requests are

Thermography Welcome!

Revised: 10/15/2013 1 FULL BODY THERMOGRAPHY Thermography Welcome! Therrmography is a noninvasive imaging technique that is intended to measure temperature distribution of organs and tissues. The visual

Scripps Clinic Medical Group (SCMG) and SCRIPPS HEALTH INFORMED CONSENT STATEMENT FOR. Study Title: SCMG & Scripps Health Bio-Repository

Scripps Clinic Medical Group (SCMG) and SCRIPPS HEALTH INFORMED CONSENT STATEMENT FOR Study Title: SCMG & Scripps Health Bio-Repository Collection and Storage of Human Biological Materials for Research

Southwest Medical Thermal Imaging & Ultrasound, LLC. Informed Consent for Thermal Imaging. Patient Name: DOB:

Southwest Medical Thermal Imaging & Ultrasound, LLC Informed Consent for Thermal Imaging Patient Name: DOB: You or your physician have requested that we perform a Thermal Imaging scan to obtain additional

Informed Consent for Treatment

Informed Consent for Treatment TO THE PATIENT: You have the right, as a patient, to be informed about your condition and the recommended diagnostic, physical therapy or rehabilitation treatment/procedure

CHINA BASIN 3T MRI Safety

CHINA BASIN 3T MRI Safety Part I General Information 1. Before anyone (staff, subject, and visitor) may enter the magnet room, a screening form must be completed and reviewed by the research technologist,

Instruction Sheet for Completing Health Care Power of Attorney/Living Will (Please discard instruction sheet after completion of document)

Instruction Sheet for Completing Health Care Power of Attorney/Living Will (Please discard instruction sheet after completion of document) Overview The attached Power of Attorney for Health Care form is

ABOUT ADVANCE DIRECTIVES

ABOUT ADVANCE DIRECTIVES You have a right to decide what treatments you want or don t want, and who makes these decisions should you be unable to make them for yourself. This booklet will tell you how.

Johns Hopkins Notice of Privacy Practices for Health Care Providers

Johns Hopkins Notice of Privacy Practices for Health Care Providers This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please

~ Tennessee ~ Advance Directive and Appointment of Health Care Agent Christian Version WARNING TO PERSON EXECUTING THIS DOCUMENT

~ Tennessee ~ Advance Directive and Appointment of Health Care Agent Christian Version WARNING TO PERSON EXECUTING THIS DOCUMENT This is an important legal document. Before executing this document you

RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM. I,, have received a copy of Dr. Andy Hand s Notice of Privacy Practice.

Central Texas Institute Of Plastic Surgery, PA Dr. Andy Hand, M.D. Plastic and Reconstructive Surgery Cosmetic Plastic Surgery RECEIPT OF NOTICE OF PRIVACY PRACTICES WRITTEN ACKNOWLEDGEMENT FORM I,, have

New Patient Intake Form

New Patient Intake Form Facility Name: Patient Name: General Patient Information Weight: Height: B/P:! Hospice Past Medical History! DM (Last A1C)! Venous Stasis (Last Venous Doppler)! PAD (Last Arterial

This notice describes Florida Hospital DeLand s practices and that of: All departments and units of Florida Hospital DeLand.

MRN: FIN: FLORIDA HOSPITAL DELAND HIPAA NOTICE OF PRIVACY PRACTICES Effective Date: September 23, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN

MRI Safety Symposium. ACR Safe Practice Guidelines. An Overview of the ACR Guidance Document on MR Safe Practices. Zachary W. Friis, Ph.D.

MRI Safety Symposium An Overview of the ACR Guidance Document on MR Safe Practices Zachary W. Friis, Ph.D.,DABR IT HAS BEEN RECOGNIZED THAT THERE ARE MANY POTENTIAL RISK IN THE MR ENVIRONMENT. NOT TO JUST

UBC MRI Research Centre 7T Facility SAFETY POLICY

THE UNIVERSITY OF BRITISH COLUMBIA UBC MRI Research Centre 7T Facility SAFETY POLICY June 13, 2007 The following document contains important safety information with respect to the 7T Facility at the UBC

GEORGIA S ADVANCE DIRECTIVE FOR HEALTH CARE

GEORGIA S ADVANCE DIRECTIVE FOR HEALTH CARE The Georgia General Assembly has long recognized the right of individuals to control all aspects of their personal care and medical treatment, including the

Patient Consent Form

Alexander Raskin, M.D., Q.M.E. Assistant Clinical Professor UCLA School of Medicine ORTHOPEDIC SURGERY SPORTS MEDICINE ARTHROSCOPY 16311 Ventura Blvd., Suite 1150, Encino, CA 91436 T (818) 788-ORTHO (6784)

NOTICE OF PRIVACY PRACTICES

BUTTE COUNTY DEPARTMENT OF BEHAVIORAL HEALTH NOTICE OF PRIVACY PRACTICES Effective Date: 4/14/2003 THIS NOTICE DESCRIBES NOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS

Mediastinal Venogram and Stent Insertion

Mediastinal Venogram and Stent Insertion Radiology Department Patient information leaflet This leaflet tells you about the procedure known as a mediastinal venogram. It explains what is involved and the

CLARK HEARING SOLUTIONS NEW CLIENT REGISTRATION FORM (Please Print Clearly)

Today s date: Last name: Name: CLARK HEARING SOLUTIONS First NEW CLIENT REGISTRATION FORM (Please Print Clearly) PERSONAL INFORMATION Middle Initial: Preferred Name: Birth date: Age: Sex: Occupation: /

Quality Assurance Peer and Practice Assessment. Multi-Source Feedback Assessment Handbook

Quality Assurance Peer and Practice Assessment Multi-Source Feedback Assessment Handbook - 2018 Table of Contents Introduction... 3 Peer and Practice Assessment by means of MSF Assessment... 4 The MSF

LifeBridge Health HIPAA Policy 4. Uses of Protected Health Information for Research

LifeBridge Health HIPAA Policy 4 Uses of Protected Health Information for Research This Policy contains the following Sections: I. Policy II. III. IV. Definitions Applicability Procedures A. Individual

Research Consent Form

Research Consent Form Title of Study: DRI-Renown Health Population Health study Principal Investigator: Joseph Grzymski, PhD Co-Investigators: Christos Galanopoulos, MD; Christopher Rowan, MD Study contact:

POWER OF ATTORNEY FOR HEALTH CARE

POWER OF ATTORNEY FOR HEALTH CARE Name: Date of Birth: Address: Telephone: I intend by this document to create a Power of Attorney for Health Care. My executing this power of attorney is voluntary. I expect

Form B - For those enrolled in other insurance

Form B - For those enrolled in other insurance PATIENT REGISTRATION Please print clearly so that we can process your information quickly and efficiently. Thank you! Name (First, M.I., Last) Date of Birth

PATIENT INFORMATION SHEET Laser assisted versus standard ultrasound cataract surgery

PATIENT INFORMATION SHEET Laser assisted versus standard ultrasound cataract surgery A Randomised Comparison of Femtosecond Laser Assisted vs Standard Phacoemulsification Cataract Surgery for Adults with

POLICY AND PROCEDURE. Coverage Conditions A sterilization will be covered by Medi-Cal only if the following conditions are met:

POLICY AND PROCEDURE Policy Manual: Medi-Cal Manual Origination Date: 2006 Policy #: III STD 9.1 Policy Title: Sterilization Revision Dates: Standards/ Services Last Reviewed Date: 4/06 Page 1 of 8 Applies

STANDARD OPERATING PROCEDURE FOR GENERAL SAFETY

STANDARD OPERATING PROCEDURE FOR GENERAL SAFETY SOP Number: 3T MRI 200.03 Version Number & Date: 3rd version; 01 Feb 2009 Effective Date: 01 Feb 2009 Superseded Version Number & Date (if applicable): 200.02

UPPER BODY THERMOGRAPHY PATIENT INFORMATION

PATIENT INFORMATION Therrmography is a noninvasive imaging technique that is intended to measure temperature distribution of organs and tissues. The visual display of this temperature information is known

BON SECOURS RICHMOND NOTICE OF PRIVACY PRACTICES

BON SECOURS RICHMOND NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFEULLY.

Giving Someone a Power of Attorney For Your Health Care

Giving Someone a Power of Attorney For Your Health Care A Guide with an Easy-to-Use, Legal Form for All Adults Prepared by The Commission on Law and Aging American Bar Association This publication was

Vermont Advance Directive for Health Care

Vermont Advance Directive for Health Care Prepared by the Vermont Ethics Network Explanation and Instructions You have the right to give instructions about what types of health care you want or do not

Annex VIIIA Guideline for correct preparation of a model patient information sheet and informed consent form (PIS/ICF)

DEPARTMENT OF MEDICINAL PRODUCTS FOR HUMAN USE Annex VIIIA Guideline for correct preparation of a model patient information sheet and informed consent form (PIS/ICF) Version 10 th November 2016 Date of

Legally Authorized Representatives in Clinical Trials

Vol. 7, No. 3, March 2011 Can You Handle the Truth? Legally Authorized Representatives in Clinical Trials By Judy Katzen The sickest patients need the best medical care, which might involve participation

NOTICE OF PRIVACY PRACTICES

EFFECTIVE DATE: APRIL 14, 2003 NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW

MAIN STREET RADIOLOGY

MAIN STREET RADIOLOGY PATIENT REGISTRATION FORM **OFFICE USE ONLY** TODAY S DATE: MR#: LAST NAME: FIRST NAME: ADDRESS: APT: CITY: STATE: ZIP CODE: HOME PHONE #: ( ) - CELL PHONE#: ( ) - DATE OF BIRTH:

PATIENT BILL OF RIGHTS & NOTICE OF PRIVACY PRACTICES

Helping People Perform Their Best PRIVACY, RIGHTS AND RESPONSIBILITIES NOTICE PATIENT BILL OF RIGHTS & NOTICE OF PRIVACY PRACTICES Request Additional Information or to Report a Problem If you have questions

Issues of. Informed Consent. Mitchell E. Parrish, JD, RAC, CIP Regulatory Attorney

Issues of Informed Consent Mitchell E. Parrish, JD, RAC, CIP Regulatory Attorney Part I Part II Regulatory Requirements Key Considerations Part III Elements of Consent Part IV Summary 2 PART I 3 Informed

Lipo Laser Weight Loss Action Plan

7921 Tanner Williams Road, Ste B Mobile, AL 36608 Phone 251.607.0040 Fax 251.607.7202 Lipo Laser Weight Loss Action Plan 1. Your first appointment today will consist of a consultation with a doctor. This

APPOINTMENT INFORMATION SHEET

APPOINTMENT INFORMATION SHEET All appointments for new patients will require a one-time, refundable deposit of $50.00 to secure your appointment. You may use cash, check or credit card. The check or credit

Advance Medical Directives

Advance Medical Directives What Are Advance Medical Directives? These documents could be a living will or a durable power of attorney for health care (also called a health-care proxy). They allow you to

Inferior Vena Cava (IVC) Filter Insertion

Patient information leaflet Royal Surrey County Hospital NHS Foundation Trust Inferior Vena Cava (IVC) Filter Insertion Radiology This leaflet informs you about the procedure known as an Inferior Vena

TRINITY DENTAL CLINIC Medical History Form Date:

Page 1of 4 TRINITY DENTAL CLINIC Medical History Form Date: NAME DATE OF BIRTH ADDRESS CITY STATE ZIP PHONE NUMBERS PHYSICIAN DO WE HAVE PERMISSION TO LEAVE A MESSAGE AT THE PHONE NUMBERS LISTED ABOVE?

PATIENT INFORMATION Please Print

PATIENT INFORMATION Please Print DATE Patient s Last Name First Name Middle Name Suffix Gender: q Male q Female Social Security Number of Birth Race Ethnic Group: q Hispanic q Non-Hispanic q Unknown Preferred

INFORMED CONSENT TO PARTICIPATE IN A DIABETES RESEARCH REGISTRY

INFORMED CONSENT TO PARTICIPATE IN A DIABETES RESEARCH REGISTRY PRINCIPAL INVESTIGATOR: Andrew S. Pumerantz, DO 795 E. Second Street, Suite 4 Pomona, CA 91766-2007 (909) 706-3779 CO-INVESTIGATORS: WDI

Advance Directive. What Are Advance Medical Directives? Deciding What You Want. Recording Your Wishes

Advance Directive What Are Advance Medical Directives? These documents could be a living will or a durable power of attorney for healthcare (also called a healthcare proxy). They allow you to give directions

Notice of Health Information Privacy Practices Acknowledgement

I understand that as part of my healthcare, Sonoma Valley Hospital and its medical staff creates, receives and maintains health records describing my health history, symptoms, examination and test results,

Percutaneous Transhepatic Cholangiogram (PTC) and Biliary Stent

Percutaneous Transhepatic Cholangiogram (PTC) and Biliary Stent Radiology Department Patient information leaflet This leaflet informs you about the procedure known as a Percutaneous Transhepatic Cholangiogram

Patient rights and responsibilities

Patients have rights and responsibilities, and this leaflet will provide you with more information on what you can expect from us, and what we expect of you. Erasmus MC Erasmus MC is a university medical

Final Choices Faithful Care

Final Choices Faithful Care A guide to important medical decisions and how to share them with those involved in your care. Mercy Health System is committed to providing care to our patients through all

Psychological Services Agreement

John A. Watterson, Ph.D. 4101 Parkstone Heights Drive, Suite 260 Austin, Texas 78746 Phone: 512-306-0663 Fax: 512-306-8086 Website: www.johnwatterson.com Psychological Services Agreement Welcome to my

Mediastinal Venogram and Stent Insertion

Patient information leaflet Royal Surrey County Hospital NHS Foundation Trust Mediastinal Venogram and Stent Insertion Radiology This leaflet tells you about the procedure known as a mediastinal venogram.

APPOINTMENT OF A HEALTH CARE AGENT (Part One)

ADVANCE DIRECTIVES As a public service project, the Health Law Section of the Maryland State Bar Association has prepared the attached Advance Directive. This form gives instructions as to your wishes

Percutaneous Transhepatic Cholangiogram (PTC) and Biliary Stent

Patient information leaflet Royal Surrey County Hospital NHS Foundation Trust Percutaneous Transhepatic Cholangiogram (PTC) and Biliary Stent Radiology This leaflet informs you about the procedure known

Patient Appointment Agreement

Patient Appointment Agreement Welcome and thank you for choosing the East Carolina University School of Dental Medicine for your oral health care needs. We are committed to providing you with the best

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE

GEORGIA ADVANCE DIRECTIVE FOR HEALTH CARE By: Date of Birth: (Print Name) (Month/Day/Year) This advance directive for health care has four parts: PART ONE HEALTH CARE AGENT. This part allows you to choose

Durable Health Care Power of Attorney and Appointment of Health Care Agent and Proxy

Durable Health Care Power of Attorney and Appointment of Health Care Agent and Proxy NOTICE TO ADULT SIGNING THIS DOCUMENT: This is an important legal document. Before executing this document, you should

ADVANCED PLASTIC SURGERY, PLLC. NOTICE OF PRIVACY PRACTICES

Effective Date: July 1 st 2013 ADVANCED PLASTIC SURGERY, PLLC. NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO

Pediatric Psychology

Pediatric Psychology Welcome to Pediatric Psychology at CHOC Children's. Please read this information carefully and write down any questions that you might have, so that we can discuss them. PSYCHOLOGICAL

UW MEDICINE PATIENT EDUCATION. Angiography: Radiofrequency Ablation to Treat Solid Tumor. What to expect. What is radiofrequency ablation?

UW MEDICINE PATIENT EDUCATION Angiography: Radiofrequency Ablation to Treat Solid Tumor What to expect This handout explains radiofrequency ablation and what to expect when you have this treatment for

Columbia Medical Practice- Pediatrics Ken Klebanow M.D. and Associates

HOWARD COUNTY HEALTH DEPARTMENT SCHOOL-BASED WELLNESS CENTERS PROGRAM TELEMEDICINE SERVICES A partnership between the Howard County Health Department and the Howard County Public School System What is

Telemedicine Guidance

Telemedicine Guidance GEORGIA DEPARTMENT OF COMMUNITY HEALTH DIVISION OF MEDICAID Revised: October 1, 2017 Policy Revisions Record Telemedicine Guidance 2017 REVISION DATE Oct. 1, 2017 SECTION REVISION

Your Rights and Responsibilities as a Patient at Sparrow Hospital

Your Rights and Responsibilities as a Patient at Sparrow Hospital Sparrow s mission is to improve the health of the people in our communities by providing quality, compassionate care to every person, every

ETHICAL AND REGULATORY CONSIDERATIONS

CONSIDERATIONS Office for Office for Human Research Protections The Office for Office for Human Research Protections (OHRP) is an administrative subdivision within the U.S. Department of Health and Human

Advance Health Care Directive (California Probate Code section 4701)

Advance Health Care Directive (California Probate Code section 4701) PART 1 Power of Attorney For Health Care 1.1 DESIGNATION OF AGENT: I designate the following individual as my agent to make health care

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA RIVERSIDE CAMPUS HEALTH CENTER

NOTICE OF PRIVACY PRACTICES UNIVERSITY OF CALIFORNIA RIVERSIDE CAMPUS HEALTH CENTER Effective Date: April 14, 2003 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND

IRB 101. Rachel Langhofer Joan Rankin Shapiro Research Administration UA College of Medicine - Phoenix

IRB 101 Rachel Langhofer Joan Rankin Shapiro Research Administration UA College of Medicine - Phoenix Contents Brief discussion of regulations IRB Structure Levels of Approval Informed Consent HIPAA/HITECH

P R O C E D U R E L E V E L 1

P R O C E D U R E L E V E L 1 TITLE CONSENT TO TREATMENT / PROCEDURE(S) DOCUMENT # PRR-01-01 PARENT DOCUMENT LEVEL LEVEL 1 PARENT DOCUMENT TITLE Consent to Treatment/ Procedure(s) APPROVAL LEVEL Alberta

AGREEMENT FOR SERVICE / INFORMED CONSENT FOR MINORS

Introduction AGREEMENT FOR SERVICE / INFORMED CONSENT FOR MINORS This Agreement has been created for the purpose of outlining the terms and conditions of services to be provided by San Diego Psychotherapy

How to Help Write a Good Consent Form: MOVING FROM! INFORMED CONSENT to INFORMED CHOICE

How to Help Write a Good Consent Form: MOVING FROM! INFORMED CONSENT to INFORMED CHOICE Peggy Devine Founder & President Cancer Information & Support Network (CISN) C3 ASCO advocate training January 19,

~ Arizona. Power of Attorney For Health Care Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT

~ Arizona ~ Power of Attorney For Health Care Christian Version NOTICE TO PERSON MAKING THIS DOCUMENT You have the right to make decisions about your health care. No health care may be given to you over

WELCOME. Payment will be expected at the time of service. Please remember our 24 hour cancellation notice.

WELCOME Those of us at Crossroads Counseling want to thank you for choosing to work with us and we want to make your time with us as productive as possible. In order to expedite the intake process, please

Joseph Bikowski, M.D., Associates

Joseph Bikowski, M.D., Associates BIKOWSKI SKIN CARE CENTER 500 Chadwick Street Sewickley, PA 15143 Effective Date: September 20, 2013 (revised) THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU

DURABLE POWER OF ATTORNEY

Page1 DURABLE POWER OF ATTORNEY FOR HEALTH CARE I,, am of sound mind and I (Print or type your full name) voluntarily make this designation. APPOINTMENT OF PATIENT ADVOCATE I designate, my (Insert name