Due to the sensitive nature of the treatment you will be receiving, we would be happy to arrange for you to have a chaperone present in the examining room with you if you so desire.
Please indicate your decision below:
Yes, I would like to have a chaperone present during my treatment.
No, I decline to have a chaperone present during my treatment.
Please feel free to change your decision at any time during the course of your treatment by telling your therapist or the front desk of your decision, and request a new chaperone form for your signature.
Patient Name
Signature
Date
Δ
