Friday’s Free Day

Consent for treatment:

                      I, _____________________________________  understand that the visit today with Sherry Bushnell - Midwife, ABB volunteer, is for free and I do not have to render any payment. 

On this date, ___________________, this visit is done for information gathering or entertainment purposes.

         The information I am given I am to use at my own risk and refer to my physician of choice for diagnosis and treatment.

I understand that other services performed by Sherry Bushnell, Midwife, may be chargeable with my consent at a later date.

The items I am interested in having help with and consent to having done today are:

______Prenatal Check ___________________________________________________________________

______PAP / STD Testing -  __________________________________________________________________________

______   _____________________________________________________________________

_______Well Woman / Cycle Info  __________________________________________________________

_______Fertility Awareness Info   ___________________________________________________________

_______  ________________________________________________________________________________

Client Signature: __________________________________  Date _______________________

Sherry Bushnell, DEM  _______________________________  Date _____________________