I am an independently practicing professional. I am completely independent in providing you with clinical services and I alone am fully responsible for those services. My professional records are separately maintained and no one else can have access to them without your specific, written permission.
The undersigned patient or responsible party (parent, legal guardian or conservator) consents to, and
authorizes services, by June Thorpe, R.N. These services may include, post-operative care, weekly visits with medication management and setup of pill trays, wellness check-up, oversight of MD appointments, and preventive health screenings.
The undersigned understands that he/she has the right to:
1. Be informed of and participate in the selection of treatment modalities.
2. Receive a copy of this consent.
3. Withdraw this consent at any time.