Declaration and Client Consent Form - Hawthorn Clinic 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your name in the designated field at the top of the form. This personalizes your consent.
3. In section 1, list the treatments you consent to receive from Dr. Susan Ritcey. Ensure each treatment is clearly specified.
4. Review section 2 carefully, which outlines what has been explained to you regarding the treatments. Confirm your understanding of each point.
5. In section 3, provide details about any medications or health conditions you currently have. This information is crucial for your safety.
6. Section 4 confirms your ability to seek additional medical care if needed. Acknowledge this by checking the box provided.
7. Read through sections 5 to 9, ensuring you understand all statements regarding confidentiality, fees, and consent for communication.
8. Finally, sign and date the form at the bottom. If applicable, have a parent/guardian or witness sign as well.

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