Consent for Release of Information

CONSENT FOR RELEASE OF INFORMATION
Child's Name:
Date of Birth:
I authorize Wee Speech, P.C. to obtain information concerning the above named child.

Clear
I do NOT authorize Wee Speech, P.C. to release information concerning the above named child.

Clear
I authorize Wee Speech, P.C. to release information concerning the above named child.

Clear
I would like a copy of all written reports, evaluations and progress notes sent to my child's:

PediatricianSchool speech pathologist
Other recipients:
Pediatrician's Name:*
Phone Number*

Area CodePhone Number
Fax Number*

Area CodePhone Number
I understand that this authorization allows release of records and may be revoked at any time in writing.

I certify that I am the parent or legal guardian of the above named child and have the authority to sign this release.
Parent/Guardian Printed Name
Date

MonthDayYear
Date
Parent/Guardian Signature

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Email
example@example.com
Wee Speech, P.C. 8707 Skokie Blvd. Suite 402 Skokie, IL 60077 847 329 8226 www.weespeech.com
Should be Empty:

CONSENT FOR RELEASE OF INFORMATION