Substance Usage Waiver
Patient Name
First Name
Last Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
I agree with the following statements
I have informed all the risks and complications associated with substance usages such as long-term harmful changes in the brain and body. I am considering the effects of substance use and knowingly and voluntarily agree to take the substance.
I will not hold the company, their affiliates, directors, members, agents, attorneys, volunteer staff, heirs, representatives, predecessors, successors, and assigns liable for the actions and results of the treatment. Standard improvement during my participation in Treatment as a result of my use of addictive substances.
I understand that standard improvement during my participation in Treatment is a result of my use of addictive substances.
I am voluntarily agree to this disclaimer as my own decision and I release the company from any liability.
Date
-
Month
-
Day
Year
Date
Signature
Submit
Should be Empty: