Client Consent Combined Consents

CLIENT CONSENT COMBINED CONSENTS

RECITALS

WHEREAS, Client Name: ("Client") seeks certain services from Service Provider: ;

WHEREAS, the parties require Client to provide express written consents and authorizations regarding information sharing, communications, payment processing, and related matters as set forth below;

WHEREAS, by executing this combined consent form effective as of Effective Date: , Client acknowledges and agrees to the terms, limits, and revocation procedures contained herein.

SCOPE OF SERVICES

The Provider will perform the services described below. Client authorizes the Provider to take actions reasonably necessary to perform those services.

COMBINED CONSENTS (CHECK AND INITIAL WHERE INDICATED)

Client grants the following consents by checking the applicable box and initialing the line beside each item. Each checked item constitutes an independent authorization; checking one item does not affect others.

Consent to Collection and Processing of Personal Data — Client authorizes Provider to collect, process, store, and use Client personal and contact information as reasonably necessary to provide the services and to comply with legal obligations. Initials:

Consent to Disclosure to Third Parties — Client authorizes disclosure of necessary information to third parties, including contractors, affiliates, payment processors, or professional advisers when required to perform services or as permitted by law. Initials:

Consent to Electronic Communications — Client agrees to receive communications, notices, statements, and disclosures by electronic means including email, text message, and secure client portal. Client understands that consent to electronic delivery is voluntary but may be required to receive certain documents. Initials:

Consent to Telephone/Audio Recording — Client consents to recording of telephone or audio sessions for quality assurance, training, and recordkeeping, except where prohibited by applicable law. Initials:

Consent to Credit and Background Checks — Where applicable to the services, Client consents to reasonable background, credit, or identity verification checks. Client authorizes any consumer reporting agency to provide such information to Provider. Initials:

PAYMENT TERMS AND AUTHORIZATION

Client authorizes Provider to charge fees for services performed under this agreement according to the schedule below. Client agrees that failure to pay amounts when due constitutes a breach and may result in suspension or termination of services.

Authorization to Charge — Client expressly authorizes Provider to charge the Client's designated payment method for agreed fees and any applicable late charges in accordance with the payment schedule above.

TERM AND TERMINATION

The consents and authorizations provided in this Combined Consents form commence on Start Date: and continue until End Date: , unless earlier revoked in writing as provided below.

Revocation of any consent must be delivered in writing and will be effective upon Provider's receipt, except where Provider has taken actions in reliance on the consent prior to receipt of revocation. Revocation will not affect disclosures or processing already completed in reliance on a previously valid consent.

CONFIDENTIALITY

Provider shall use reasonable administrative, technical, and physical safeguards to protect Client information and shall not disclose confidential information except as permitted by this Combined Consents form, by prior written authorization of Client, or as required by law. Confidential information does not include information that (a) is or becomes public other than through Provider's breach, (b) was lawfully received from a third party without restriction, or (c) is independently developed by Provider without use of Client's confidential information.

GOVERNING LAW; DISPUTE RESOLUTION

This Combined Consents form shall be governed by the laws of Governing State: , without regard to its conflict of laws principles. Any dispute arising out of or relating to this form shall be resolved in the state or federal courts located in that jurisdiction, and the parties submit to the exclusive jurisdiction of those courts.

ENTIRE AGREEMENT

This Combined Consents form constitutes the entire agreement between Client and Provider regarding the consents and authorizations contained herein and supersedes all prior or contemporaneous oral or written agreements related to such consents. Any amendment must be in writing and signed by both Client and an authorized representative of Provider.

ACKNOWLEDGMENT AND CERTIFICATION

By signing below, Client certifies that Client has read and understands each consent checked above, that Client has had the opportunity to ask questions and obtain answers, and that Client's execution of this Combined Consents form is voluntary, knowing, and without coercion. Client further certifies that the information provided in this form is true and correct to the best of Client's knowledge.

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