Client Demographics

Client Demographics
Client Information
Last Name
First Name
School
Date of Birth

Month Day Year
Date
Age
Sex

M F
Address

Address

Street Address Line 2

City

Zipcode
Diagnosis
Sponsor SSN *
Residence
Home with parents Foster Care Other
Mother/Caregiver Name
Occupation
Home Address
Home Phone Number
Cell Phone Number
Email
example@example.com
Father/Caregiver Name
Occupation
Home Address
Home Phone Number
Cell Phone Number
Email
example@example.com
Primary Care Physician
Physician Name
Phone
Fax
Address

Address

Street Address Line 2

City

Zipcode
Referring Physician
Physician Name
Phone
Fax
Address

Address

Street Address Line 2

City

Zipcode
I authorize this office to bill my insurance as a courtesy only and agree to pay my account in full if either fails to pay their portion. Should legal and/or collection agency action become necessary, I agree to pay these costs I authorize my insurance carrier to remit payment directly to Optimize Speech-Language Therapy Services.
Parent/Guardian (please print name)
Signature *

Clear
Date

Month Day Year
Date
Please verify that you are human *
Should be Empty: