Washington
General Consent

For Patient Review

Welcome to Bonmente, a practice specializing in mental health and psychiatric wellness. At this point in your care, no specific treatment plan has been recommended, until we have had the opportunity to identify your needs. This consent form is simply to obtain your permission to perform the evaluation necessary to identify any condition that might require an appropriate treatment as part of your plan of care. I consent to my provider(s) reviewing my previous medication history from the pharmacy database and from Washington’s Prescription Monitoring Program (PMP). 

I understand that the medication prescribed to me maybe a controlled substance and must be used only as directed. I agree to take the medication responsibly, not share it with others, and follow all refill and monitoring requirements set by my provider. I acknowledge that misuse or noncompliance may result in changes to my treatment plan and or termination of care. 

You have the right to be informed about any condition identified and the options for recommended medical care that may include diagnostic procedures. You may then decide whether or not to undergo any suggested treatment or procedure after being informed of the potential benefits and risks involved. 

The undersigned patient and/or responsible relative or person hereby consents to, authorize, and request a Bonmente healthcare provider (psychiatrist, nurse practitioner, physician assistant, and/or a therapist) to administer and perform any and all medical examinations and treatments, diagnostic procedures, therapy, and other interventions which may now or during the course of the patient care be deemed advisable or necessary. I acknowledge that I may be seen by a provider that is an independent contractor and not an employee of Bonmente. 

This consent provides us with your permission to perform reasonable and necessary medical examinations, treating, and treatment. By signing below, you are indicating that you understand that this consent is continuing in nature even after a specific diagnosis has been made and treatment recommended, along with the potential risks and benefits. This consent will remain fully in effect until it is revoked in writing. You have the right at any time to ask additional questions or to discontinue or decline services. 

I consent to receive text messages that pertain to my appointments, no-shows, and well checks notifications to my cell phone. I understand data charges may apply.  

You have the right to discuss the treatment plan with your healthcare provider about the purpose, potential risks and benefits of any test or treatment ordered for you. If you have any concerns regarding any test or treatment recommended by your healthcare provider, we encourage you to ask questions. 

You have the right to discuss the treatment plan with your healthcare provider about the purpose, potential risks and benefits of any test or treatment ordered for you. If you have any concerns regarding any test or treatment recommended by your healthcare provider, we encourage you to ask questions. 

I voluntarily request a healthcare provider, or the designees as deemed necessary, to perform reasonable and necessary medical examination, testing, and treatment for the condition that brought me to seek care at this practice or on that has been identified.  

I understand that after examining me, my doctor may make certain recommendations based on what he or she feels is best for my health. This might include prescribing medication, referring me to a specialist, ordering labs and tests, or even asking me to return to the office within a certain period of time. I understand that not following my treatment plan can have serious negative effects on my health.  I will let my doctor know whenever I decide not to follow his or her recommendations so that he or she may fully inform me of any risks associated with my decision to delay or refuse treatment.

Thank you for your partnership. As our patient, you have the right to be informed about your health care. We invite you, at any time, to ask questions, report symptoms, or discuss any concerns you may have. If you need more information about your health or condition, please ask.

As an outpatient mental health office our office reserves the right to refuse services based on your acuity levels, diagnosis that we can not safely treat, and failure to comply to our clinical and administrative policies. 

By signing, I certify that I have read and fully understand the above statements and consent fully and voluntarily to its contents.