ACKNOWLEDGMENT OF RECORDING OF MEDICAL CONSULTATION SESSIONS

Dear Patient or Patients:

In order to provide the best medical care to you as an individual or as a couple it is our procedure to record all therapeutic and evaluative sessions.

The purpose of the recordings is for in-staff evaluation of the problem, maintaining medical records and for educational purposes regarding dealing with the problem or problems you are seeking help with. It may be necessary for us to review for the purposes of evaluation and treating your problem to have a recording which we can review and evaluate during the course of therapy.

It must be understood that these recordings will not be used out of the confines of this office except for teaching and reviewing during the course of therapy. We assure that the utmost security and confidence will be taken with these tapes.

 

Patient #1

Sign and Date

 

Patient #2

Sign and Date

 

Patient #3

Sign and Date

 

Patient #4

Sign and Date

 

Witness

Sign and Date