Medication Only Treatment Plan Sign-off "*" indicates required fields Neuropsychiatry Center 300 Old Pond Rd # 201 Bridgeville, PA 15017 Medication Only Treatment Plan Sign-offName* First Last Date of Birth* MM slash DD slash YYYY MA Number Patient (or Parent/Guardian if patient under age 14) Signature* Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY For Office Use Only:Date of Plan MM slash DD slash YYYY Medication Provider Name First Last Medication Provider Signature Reset signature Signature locked. Reset to sign again Date 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.
