Common use of Right to Withdraw Consent Clause in Contracts

Right to Withdraw Consent. I have the right to withdraw my consent for evaluation and treatment (for myself or my child) at any time by providing a written request to Gladstone Psychiatry & Wellness, LLC. • I voluntarily consent to participate in (or allow my child to participate in) evaluation and subsequent treatment as deemed medically appropriate and necessary by clinical staff at Gladstone Psychiatry & Wellness, LLC. • I attest that I have the right to consent to evaluation and treatment (for myself or my child). • I will complete the associated Parental Consent for Treatment if I am consenting to the evaluation and treatment of a minor under the age of 16. • I have read this form in its entirety or had this form read/explained to me in its entirety. • I fully understand its contents, including the potential risks and associated benefits of participating in psychiatric evaluation and treatment. • I have been given the opportunity to ask questions and all of my questions have been answered to my satisfaction. I understand that I have the right to ask questions about the above information at any time. • I understand that I have the right to withdraw my consent for evaluation and treatment (for myself or my child) at any time and I understand how to do so.

Right to Withdraw Consent. I have the right to withdraw my consent for evaluation and treatment (for myself or my child) at any time by providing a written request to Gladstone Psychiatry & Wellness, LLC. • I voluntarily consent to participate in (or allow my child to participate in) evaluation and subsequent treatment as deemed medically appropriate and necessary by clinical staff at Gladstone Psychiatry & Wellness, LLC. • I attest that I have the right to consent to evaluation and treatment (for myself or my child). • I will complete the associated Parental Consent for Treatment if I am consenting to the evaluation and treatment of a minor under the age of 16. • I have read this form in its entirety or had this form read/explained to me in its entirety. • I fully understand its contents, including the potential risks and associated benefits of participating in psychiatric evaluation and treatment. • I have been given the opportunity to ask questions and all of my questions have been answered to my satisfaction. I understand that I have the right to ask questions about the above information at any time. • I understand that I have the right to withdraw my consent for evaluation and treatment (for myself or my child) at any time and I understand how to do so.. PATIENT NAME OR NAME OF DATE WITNESS NAME (PRINTED) / DATE