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Treatment Consent
I, ___________________, consent to psychiatric evaluation and treatment by Michael B. Jackson, M. D. I understand that he does not, and cannot, guarantee any specific results. I understand that his ability to help
me/patient depends on the completeness and accuracy of the information provided to him.
2.
I consent to the exchange of information, such as diagnoses, medications prescribed, medical records, and diagnostic test results, between Dr. Jackson, hospitals, and other treating professionals when necessary to facilitate
treatment. Otherwise, I understand that psychiatric records are confidential and privileged and will not be released to
anyone without proper written authorization, unless legally required.
3.
I consent specifically to the exchange of information, both for Michael B. Jackson, MD to provide and to receive information including diagnoses, medications prescribed, medical records, and diagnostic test results from the following individuals and providers: Y Spouse/Partner/Significant Other: ________________________________Phone:__________ Therapist: ___________________________________________________Phone:__________ School counselor: _____________________________________________Phone:__________ Primary Care Physician: ________________________________________Phone:__________ Other Medical Specialists: ______________________________________Phone:__________ Other Medical Specialists: ______________________________________Phone:__________ Other (please specify):_________________________________________Phone:___________ Other (please specify):_________________________________________Phone:___________ I consent to the release to any third party payer or its agents any information necessary for the processing of a claim for services rendered. Should hospitalization be required, I consent to the release of any information
needed for utilization review. Should prior authorization of outpatient treatment or prescription drugs be required, I
consent to the release of any information needed.
5.
The undersigned agrees, whether he or she signs as guardian, agent or as patient, that in consideration of the services to be rendered to the patient, he or she hereby individually obligates himself or herself to pay the
account of the physician. Should the account be referred to an attorney or outside agency for collection, the
undersigned shall pay reasonable attorney’s fees and collection expense.
6.
I agree to the terms of Dr. Jackson’s Office and Payment Policies. I understand that I am financially responsible for all charges, and that payments are due at the end of each session. In particular, I understand that I
personally must pay the full fee for the time reserved for any appointment which I miss without 24 hours notice.
7.
This consent is subject to revocation at any time, by written request, except to the extent that action has Patient Name: _______________________________ Signature: ________________________________________
Office and Payment Policies
Medications:

• To ensure quality of care, regular follow up with routine office visits is necessary for prescriptions to be • If two or more scheduled office visits have been missed, or the time since last visit exceeds 90 days, the patient must be seen in the office before any further prescriptions are written.
Insurance:

• Dr. Jackson's Office does not participate in any insurance plan other than Consolidated Health Plans. • Dr. Jackson will provide a comprehensive receipt that can be submitted to an insurance company to facilitate out-of network re-imbursement upon request.
Payment:

• All patients are financially responsible for all charges, and payments/co-pay's are due at the end of each • Dr. Jackson's Office accepts Cash, personal checks, Visa/MasterCard. • Requests for written reports may incur an additional charge • There is a $25 charge for returned checks.
Cancellations:

• Because your appointment time has been reserved for you alone, you will be charged for cancellations/no shows with less than 24 hours notice. Charges for missed appointments must be paid prior to any further appointments can be scheduled. • Charges for missed appointments are not covered by insurance and are automatically charged to the credit card on file unless prior arrangements are made. • For patients with Consolidated Health Plans insurance, please note that missed visit charges include the amount normally covered by the insurance company in addition to the copay amount. I have read and agree to the policies listed above: _______________________________ Date: ______________

E-mail/Text Message Policies

Dr. Jackson utilizes e-mail for scheduling/rescheduling appointments and non-patient care related communications.
Please be aware that the transfer of information via email is not a secure and confidential form of
communication.

Dr. Jackson does not communicate via encrypted email and thus strict confidentiality cannot be guaranteed.
Dr. Jackson cannot account for what the various e-mail hosting entities may do with the information contained in an
email, and strongly discourages all prospective and current patients from including any health or treatment related
information in an email communications with Dr. Jackson.
Dr. Jackson's office does not send or receive Text Messages of any kind.
Signature of acknowledgement of above: _______________________________ Date: ____________________
Due to the increased incidents of non-payments, all patients must
have a credit card on file.
Please provide Visa or MasterCard (credit or debit) information below. This will only be used in the event of returned checks or other forms of non-payment, unless otherwise requested by the patient. Thank you. Credit Card # _________________________________________ Exp. Date ______________Three Digit Security Code_________ Print Name ____________________________________________ Signature _____________________________________________ M I C H A E L B . J A C K S O N , M . D . , L L C
General and Forensic Psychiatrist and Diplomate of the American Board of Psychiatry & Neurology
New Patient Information Form

Name:__________________________________________________________________ Today’s date:____________________ Date of birth:______/______/______ Birthplace:______________________ Social security #_________-______-___________ Home address:______________________________________________________________Phone: _______________________ _______________________________________________________________________________________________________ Email address:___________________________________________________________________________________________ Primary care physician:______________________________________________________ Phone:________________________ Therapist:_________________________________________________________________Phone:________________________ Pharmacy:_________________________________________________________________Phone:________________________ Emergency Contact:___________________________________________________________________Phone:________________________ Spouse/Partner Name:________________________________________________________Phone:________________________ Children (names and ages if any): ___________________________________________________________________________ _______________________________________________________________________________________________________ Home address:___________________________________________________________________________________________ _______________________________________________________________________________________________________ Educational Level Obtained:________________________________________________________________________________ Occupation:_____________________________________________________________________________________________ Employer name:___________________________________ Job title:_______________________________________________ Employment address:_____________________________________ Phone: __________________________________________ ________________________________________________________________________________________________________ Who referred you to this office? _____________________________________________________________________________ For what problem(s) do you seek help?
________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Medication History
Please list any medications/doses you are now taking. Take care to include all prescribed medication and any
over-the counter medication/supplement (this includes vitamins, diet pills/drinks and herbal preparations).

________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ Please list all psychiatric medications that you have taken in the past. Please include the dosage, length of
medication trial, and effects (both positive and negative).

________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ _______________________________________________________________________________________________________ ________________________________________________________________________________________________________ Please circle each of the following that you have taken, (even once):

Stimulants/ ADHD Medications
Adderall
/Adderall XR
Strattera/atomoxetine
Ritalin/Concerta/Metadate/Methylin/methylphenidate
Focalin/dexmethylphenidate
Cylert/pemoline
Provigil/modafinil
Intuniv/guanfacine
Vyvanse/lisdexamfetamine Nuvigil/armodafinil
Dexedrine/dextroamphetamine sulfate

Antidepressants/Anti-Anxiety Agents
Prozac
/Sarafem/fluoxetine
Zoloft/sertraline
Paxil/Pexeva/paroxetine
Luvox/fluvoxamine
Celexa/citalopram
Lexapro/escitalopram
Effexor/venlafaxine
Cymbalta/duloxetine
Wellbutrin/Zyban/bupropion HCl
Remeron/mirtazapine
Elavil/Endep/amitriptyline Pamelor/Aventyl/nortriptyline
Sinequan/Adapin/doxepin
Tofranil/imipramine
Norpramin/desipramine
Vivactil/protriptyline
Triavil/Etrafon Limbitrol Surmontil/trimipramine
Anafranil/clomipramine
Asendin/amoxapine
Ludiomil/maprotiline
Desyrel/trazodone
Serzone/nefazodone
Nardil/phenelzine
Parnate/tranylcypromine
Marplan/isocarboxazid
Eldepryl/deprenyl/selegiline
Pristiq/Desvenlafaxine
Aplenzin/ bupropion BrCl
Emsam/selegiline
BuSpar/buspirone
Viibryd/Vilazodone

Mood Stabilizers & Anticonvulsants

Lithium
/Eskalith/Lithobid
Depakote/Depakene/valproic acid
Lamictal/lamotrigine
Tegretol/Epitol/Equetro/carbamazepine
Trileptal/oxcarbazepine
Neurontin/gabapentin
Lyrica/pregabalin
Topamax/topiramate

Anti-anxiety medications/ Tranquilizers/ Sleeping Medications
Valium
/diazepam
Librium/chlordiazepoxide Tranxene/clorazepate
Paxipam/halazepam
Centrax/prazepam
Serax/oxazepam
Ativan/lorazepam
Xanax/alprazolam
Klonopin/clonazepam
Dalmane/flurazepam
Restoril/temazepam
Doral/quazepam
Halcion/triazolam
ProSom/estazolam
Ambien/zolpidem
Sonata/zaleplon
Lunesta/eszopiclone
Rozerem/ramelteon
Vistaril/Atarax/Hydroxyzine
Tenex/guanfacine
Catapres/Clonidine
Silenor/Sinequan /doxepin
Antipsychotics/Neuroleptics/ Mood Stabilizers
Risperdal
/risperidone
Clozaril/clozapine
Zyprexa/olanzapine
Seroquel/quetiapine
Geodon/ziprasidone
Abilify/aripiprazole
Artane/trihexyphenidyl
Cogentin/benztropine
Thorazine/chlorpromazine
Mellaril/thioridazine
Serentil/mesoridazine
Latuda/lurasidone
Trilafon/perphenazine
Stelazine/trifluoperazine
Prolixin/fluphenazine
Compazine/prochlorperazine
Torecan/Norzine/thiethylperazine
Haldol/haloperidol
Orap/pimozide
Navane/thiothixene
Taractan/chlorprothixene
Moban/molindone
Loxitane/loxapine
Symbyax/ olanzapine+fluoxetine
Invega/ paliperidone
Saphris/asenapine
Fanapt/Iloperidone

Others
Aricept
/donepezil
Exelon/rivastigmine
Reminyl/galantamine
Namenda/memantine
Symmetrel/amantadine

Source: http://hobokenpsychiatrist.com/new%20patient%20forms_Dr.Jackson.pdf

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