Liability Waiver and Consent Form

In the event your child has a medical emergency while receiving services or in the care of a Wee Speech, P.C. employee, I

give permission for Wee Speech, P.C. staff to use preventative or emergency medication as documented in a formal and up to date protocol from my child's physician. I understand Wee Speech, P.C. employees may require training on the protocol by myself and or a medical professional. I understand it is my responsibility to provide Wee Speech, P.C. with timely updates on medical information related to my child's condition including but not limited to preventative or response procedures and changes in medications. I understand Wee Speech, P.C. employees are not medically trained personnel and our facility does not have sanitizing protocols necessary to perform medical procedures. By signing this document, I give consent and waive all liability, as allowed by law (initial the line to consent to that use):

1. Wee Speech,P.C reserves the right to call for emergency medical services if loss of consciousness, irregular or stopped breathing, or under other circumstances at their discretion which will supersede protocol.

2. Wee Speech, P.C. and its employees will not be liable for any injuries or complications associated with the method of delivery of the protocol or medication, including but not limited to incorrect or untimely administration.

3. Wee Speech, P.C. and its employees will not be liable for any cost associated with emergency transport or other medical costs incurred. Our first priority is always your child's safety.

I understand that I may revoke this consent at any time by requesting to revoke consent in writing and delivering the request to Wee Speech, P.C., 8707 Skokie Blvd., Ste. 402, Skokie IL 60077. Revoked consent will be honored except to the extent that the action has been taken thereon. If consent is revoked, and in the event your child has a medical emergency while in the care of a Wee Speech, P.C. employee, Wee Speech will no longer administer any preventative treatment or medication and will require a caregiver to be present to follow the protocol in the event a medical emergency should occur while receiving services from Wee Speech, P.C. I further understand that this consent will expire when services with Wee Speech, P.C. are terminated.