Consent to Treat


Consent to Treat Form

  1. By clicking “I agree,” I give permission for Laurenmarie Cormier, FNP to give me medical treatment.
  1. I allow HEALTHCARE INTERMEDIARIES LLC to submit bills for services rendered on behalf of Laurenmarie Cormier to pay for the care I receive. I understand that:
  • I must pay my share of the costs.
  • I must pay for the cost of these services if my insurance does not pay or I do not have insurance.
  1. I understand:
  • I have the right to refuse any procedure or treatment.
  • I have the right to discuss all medical treatments with my clinician.