Please note that children under 18 must be accompanied by a legal guardian. Adults with guardians must obtain written consent from the legal guardian prior to being served. (Please provide a copy of guardianship papers for Adults).
I understand that AWS, Inc. has a Med Clinic to offer Medication Management services for their Medicaid and non-Medicaid participants. This information has been discussed with me and I have made the following choice. I have chosen AWS, Inc. to provide the services to me that have been marked with a check. These services are listed below.
I understand and consent to these treatment services and that I may stop treatment services at any time. I also understand that I may refuse to take medication and/or revoke consent at any time. This authorization is to remain in effect for one year or until revoked in writing. My signature below indicates that I have read and understand this consent/choice form.