TARAL SHARMA, MD, PC

120 PELHAM LN

Phone: (864) 844 – 9432

Fax: (864) 844-9430

Informed Consent to Treatment Form:

At my own discretion I am requesting treatment at the Taral Sharma MD, PC (120 Pelham Lane, Anderson, SC 29621). I know that my treatment may consist of psychotherapy or a combination of psychotherapy and pharmacotherapy. I will be educated to the benefits and potential side effects or reactions that may result from any prescribed medication. I am aware that I have the right to request a copy of the Physician Desk Reference for my use. This book contains detailed information about prescription medications, adverse affects, and appropriate warnings. I have the right to ask questions regarding my treatment and expect that my questions will be answered to my full satisfaction. If I do withdraw from treatment, I have the right to have a referral to another practitioner for alternative treatment.

I agree to allow the Taral Sharma M.D., P.C. to make this document a permanent part of my patient record.

Finally, I understand and will expect that all papers and documents concerning my treatment at the Taral Sharma M.D., P.C. will be kept confidential. No information concerning my treatment can be released without my specific written consent except as required by law or in a situation deemed potentially life-threatening. According to Federal Regulations, licensed providers are mandated to report information that professional judgment would determine constitutes threat or serious harm to self or others, or indicates child or elder abuse or neglect. You have my consent, without reservation, to release any such information about me without further written approval.

Patient’s Name (printed):
Signature of Patient or Legal Guardian:
Date Signed:
Signature of Witness (Taral Sharma, MD, PC, Staff Member):
Date Signed: