By continuing with this consultation, I affirm and truthfully state the following:
Age & Consent
- I am an adult of sound mind and judgment and at least 18 years of age.
- If the patient is under 18, a parent or legal guardian must accept this agreement and be present during all consultations.
Scope of Care
- I agree that Pleasant Valley Health Services (PVHS) is not a primary care provider. PVHS offers psychiatric and wellness services only.
- I agree to maintain an ongoing relationship with a licensed primary care provider (PCP) for annual physicals, routine screenings, chronic disease management, urgent care, and emergencies.
Medication Requests & Use
- Any medication(s) prescribed by PVHS are for my personal medical use only and will not be shared, sold, or stockpiled beyond an adequate supply.
- I agree to take prescribed medication(s) exactly as directed and to report any side effects, complications, or concerns to PVHS or my PCP immediately.
- Before taking any new over-the-counter or prescription medications from another source, I will consult PVHS, my PCP, or a licensed pharmacist.
Medical History & Disclosure
- I have provided PVHS with a complete and accurate medical history, including current medications, allergies, and relevant health conditions.
- I affirm that I have not knowingly omitted or misrepresented any information.
- I understand that full disclosure is essential for my safety.
Follow-Up & Emergencies
- I will seek immediate medical attention from my PCP, an urgent care facility, or emergency services (call 911) for any serious or life-threatening condition.
- I understand that PVHS may contact me regarding my care, and I consent to such contact.
Understanding of Risks & Benefits
- I acknowledge that every treatment and medication has potential risks and benefits.
- I have had the opportunity to ask questions and understand the purpose, potential side effects, and alternatives to any treatment offered.
Patient Conduct & Agreement
- I agree to adhere to PVHS policies, including attendance, respectful communication, and compliance with treatment plans.
- I understand that PVHS reserves the right to discontinue care if I fail to comply with agreed-upon treatment recommendations or policies.
By proceeding with services at PVHS, I acknowledge that I have read, understood, and voluntarily agree to all the statements above. I know that this agreement remains in effect for the duration of my care with PVHS.