PLAINFIELD HEALTH CENTER
1700-58 Myrtle Avenue
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
Signature__ _______________________________ Date:______________
copyright © PHC 2004