Neuropsychiatry Center
300 Old Pond Rd # 201
Bridgeville, PA 15017
Medication Only Treatment Plan Sign-off

Name*
MM slash DD slash YYYY
MM slash DD slash YYYY

Please Choose Your Provider:

MM slash DD slash YYYY
MM slash DD slash YYYY

My signature indicates that I have participated fully in the development and review of my individual treatment plan and agree with the plan. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.