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Informed consent for venus cha... INFORMED CONSENT FOR VENUS CHAIRS IDE TOOTH WHITENING TREATMENTBackground: We provide this information to give you insight into Chair side professional tooth whitening. Your cooperation and understanding

Pm form 3151 print form inform... PM FORM 3.15.1 Print Form Informed Consent for Psychotropic Medication Treatment (Link to Spanish Version) I have discussed the following information with my behavioral health medical practitioner

Informed consent example 13701... Example of an Informed Consent Form for an Online Survey An Investigation of the Relationship between Women's Weblogs and their Online and Real Li e” Friendships Informed Consent Form Purpose of

Patient informationinformed co... IPLEDGECommitted to Pregnancy Prevention P.O. Box 29094 Phoenix, AZ 85038 Patient Information/Informed Consent (for all patients): To be completed by patient (and parent or guardian if patient is

Informed consent for treatment... COLUMBIA RHEUMATOLOGY DEREK J. PEACOCK, MD Informed Consent for Treatment with and Discharge Instructions Important: You should not receive if you are already receiving. And are the same medicine.

Normatec informed consent form Compression Therapy Informed Consent Compression therapy is a noninvasive modality proven to increase circulation and range of motion, reduce pain and soreness, boost pressure to pain threshold and

Informed consent and release o... Utah DHS-DCFS Revised May 2006 INFORMED CONSENT AND RELEASE OF LIABILITY The Utah Department of Human Services Division of Child and Family Services is authorized to investigate any past and present child abuse information which may be pertinent to your application according to UCA 62A-4a-1006 and UCA 78-30-3. 5. The release of any and all information is authorized whether it is of record or not. Please PRINT or TYPE filling in all requested information and sign in the place marked Applicant Signature. Please do not use initials to represent your first or middle name. However if your first or middle name consists of only an initial please indicate. Example J*R* initials only Doe. A complete street address is required in addition to P. O. Box numbers. All applicants are required to submit a legible copy of one of the following photo identifications Valid Drivers License State Identification Card or Passport I. D. Processing will not occur unless all requested information signatures and copy of photo I. D. are attached* Please send completed form and copy of photo identification to Utah Division of Child and Family Services 120 North 200 West Suite 225 Salt Lake City Utah 84103-1500 Attn Child Abuse Background Review Coordinator First Name Middle Name Last Name Date of Birth mm/dd/yy Social Security Number Daytime Telephone Number Home Street Address PO Box City State and Zip Code Former Names Used Including Married and Unmarried Name Dates Used from-to Other Names Used Initials Nickname Middle Name etc* Reason you are requesting a background screening Private Adoption Step Parent Adoption Employment/Volunteer work through name of agency Other please explain By signing below I certify that I have read and understand this entire form and that the information I have provided here is true accurate and complete to the best of my knowledge. I understand that providing false or incomplete information may result in delaying or possibly denying my request for background screening. It is also my understanding that under Utah Law it is a crime for an unauthorized person to require me to request a background screening as a condition of employment. I also understand that the Division of Child and Family Services may not release the results of this background screening unless I give my written consent or unless such is authorized by law. I do hereby release all persons and entities from any legal liability for furnishing such information to the State of Utah Division of Child and Family Services. Please send the results of this background screening to Name Address/City/State/Zip Code Telephone Number Applicant Signature Date. 5. The release of any and all information is authorized whether it is of record or not. Please PRINT or TYPE filling in all requested information and sign in the place marked Applicant Signature. Please do not use initials to represent your first or middle name. However if your first or middle name consists of only an initial please indicate.

Informed consent to occlusal e... INFORMAL TONAL USE ONLY INFORMED CONSENT TO CAUSAL EQUILIBRATING Selective reshaping of the chewing surfaces of teeth with the intention to reposition the mandible and stress relieve the muscle in

Informed consent anthropology Factors Leading to Vegetarianism Title Jane Doe Names of student researchers Bob Smith 435-7890 Contact numbers jdoe hotmail.com Imogene Lim Faculty name Anthropology Faculty Supervisor 250 753-3245 x1111 We are students in an ethnographic research methods course ANTH 326 at to vegetarianism. Purpose During this study you will be asked to answer some questions as to why you became a vegetarian. This interview was designed to be approximately a half hour in length Estimated Duration. Vancouver Island University Department of Anthropology Sample Informed Consent Form for Interviews Preamble Information marked xxx is for your information and should not be included in your form. Adaptation of this template should be discussed with your supervisor. The researcher has reviewed the individual and social benefits and risks of this project with me Students should review minimal risks checklist prior to interview. I grant permission for the use of this information for a Participant to initial permission paper class presentation I grant permission to use one of the following Participant to initial permission My first name only My full name Just a pseudonym I will be given a copy of the Participant to initial permission paper audiotape videotape transcribed interview photograph s Additional conditions for my participation in this research are noted here possible conditions destruction of tape audio/video return of original material s distribution of final product as well as other original material s I have read the above form and with the understanding that I can withdraw at any time and for whatever reason I consent to participate in today s interview. Indicate where e.g. locked filing cabinet at home Only the researchers and faculty supervisor mentioned above will have access to this information. This interview is designed to learn first-hand information about this topic. Upon completion of this project all data will be destroyed or stored in a secure location. Confidentiality indicate what will become of data Participant s Agreement I am aware that my participation in this interview is voluntary. I am aware the data will be used for a paper and a class presentation. I have the right to review comment on and/or withdraw information prior to the paper s submission and class presentation. The data gathered in this study are confidential and anonymous with respect to my personal identity unless I specify/indicate otherwise. However please feel free to expand on the topic or talk about related ideas. Also if there are any questions you feel you cannot answer or that you do not feel comfortable answering feel free to indicate this and we will move on to the next question* Description All the information will be kept confidential* We will keep the data in a secure place. If for any reason at any time I wish to stop the interview I may do so without having to give an explanation* I understand the intent and purpose of this research.

Mft informed consent form exam... Kristy Kirby, MFT #48653 Informed Consent Disclosure Statement & Agreement for Services (for your records) Introduction This document is intended to provide important information to you regarding

Secret rf informed consentlife... PATIENT INFORMED CONSENT FORM For Secret RF Treatment hereby authorize Dr. or, under Dr. s supervision to perform the Secret RF radiofrequency microneedling treatment. Secret RF's microneedles smoothly

Informed consent for crown and Informed consent for crown and bridge prosthetics I have been advised of and understand that treatment of dental conditions requiring crowns and/or fixed bridgework, involves certain risks and possible

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