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Sleep & Wake Clinic Consent Form

Consent Form  

                                  

I hereby give my consent to undergo the investigation and treatment, as ordered by or to be performed by the Physicians at the Sleep & Wake Clinic.

I understand I will receive a detailed explanation of the nature and anticipated effects of the proposed investigations and procedures, including its significant risks and available alternatives. At the time of discussion, I confirm that I fully understand the explanations provided regarding the treatment processes ahead and that I am satisfied with the information given.

 

 

 

 

Furthermore, I also provide consent for any additional or alternative investigations, treatments, or procedures that, in the professional opinion of the Physicians at the Sleep & Wake Clinic, are deemed immediately necessary. This may include but is not limited to referrals to external health care professionals.

Furthermore, I acknowledge that the Physicians at the Sleep & Wake Clinic may utilize the expertise of other healthcare professionals and may authorize them to carry out any part of the investigation, treatment, or procedure as necessary. I understand and agree that these healthcare professionals will exercise the same level of discretion as the Physicians at the Sleep & Wake Clinic in my investigations and treatment.

 

 

(This question is mandatory)

 

 

I commit to attending all scheduled sessions regularly and understand that it is my responsibility to inform the therapy team at least 48 hours in advance if I am unable to attend a session. I am aware that failure to do so may result in the session being counted as a late cancellation or "no show," with applicable fees required to resume treatment. I understand that repeated instances of late cancellations or no-shows may lead to the discontinuation of the therapeutic relationship unless sufficient documentation is provided.

Additionally, I grant permission for virtual sessions to be conducted if requested by myself or the Physicians at the Sleep & Wake Clinic, or deemed necessary.

Sleep & Wake Clinic
#310 1011 Glenmore Trail S.W.
Calgary, Alberta
P: 1-403-474-0800
F: 1-403-474-0837
E: admin@sleepwakeclinic.com

Disrespectful or abusive behavior is not welcomed and may result in discontinuation of services.
For more information on our workplace safety policy, please visit sleepwakeclinic.com/workplace-safety.

Please Fill Out Your Name In Full Below

Printing your name in full will be considered equivalant to your electronic signature 
(This question is mandatory)

Please complete the date of your signature

Open date/time selector

Withdrawl of Consent: 

 

 

You may withdraw your consent at any time by contacting the Sleep & Wake Clinic at admin@sleepwakeclinic.com.


 
This means you can revoke your agreement for treatment or participation at any time.
(This question is mandatory)

 

Consent for Research Purposes:

 

I provide additional consent for the use of my information anonymously for research purposes, ensuring that the research benefits patients and the public.

By agreeing, you allow the anonymous use of your data for research purposes that aim to improve patient care and public health. Your identity will not be disclosed.

 


  Thank you for taking the time to complete this consent form.

 

 

 
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