Consent for Services
I authorize Peak Pediatrics LLC to render appropriate evaluation and therapy services to the client named below in accordance with state and federal laws. I understand that care will be provided by a qualified, licensed, and trained health professional. I recognize, agree and understand that I have the right to refuse treatment or terminate services at any time by Peak Pediatrics LLC in writing. In addition, Peak Pediatrics LLC may terminate services by notifying me in writing.
I do not give my consent or am withdrawing my consent regarding Peak Pediatrics LLC rendering evaluation and therapy services to the client named below.
Print Name of Client
Date
-
Month
-
Day
Year
Client Date of Birth
-
Month
-
Day
Year
Relationship to Client
Signature of Client
Submit
Should be Empty: