PLAINFIELD HEALTH CENTER

1700-58 Myrtle Avenue
Plainfield, NJ 07063
(908) 753-6401
(908) 753-7570 FAX ____

Name of patient: __________________________________ Date of Birth: ___________

PATIENT RIGHTS AND RESPONSIBILITIES

I have received a copy of Plainfield Health Center’s PATIENT RIGHTS AND RESPONSIBILITIES and have had my questions answered.

Patient/Guardian signature x ________________________________

TH THIS FORM MUST BE COMPLETED IF A MINOR IS NOT ACCOMPANIED BY A PARENT/GUARDIAN.

As a minor, I specifically consent to diagnosis and/or treatment for the following:
(as per NJ STATUTE 530:4c(b); 59:17a-2; 17a-4)
Venereal Disease ______ Pregnancy _____ Family Planning Counseling ______
Alcohol and/or drug abuse ______ HIV Testing/Counseling ______
Emotional Problems _______

Signature__ _______________________________ Date:______________
Patient
Witness:__ _______________________________ Date:________________
PHC Staff