Consent to Treatment and Release of Information

Consent to treatment and release of information
I authorize the staff of Central Texas Therapy Spot, PLLC to:
1. Administer and perform those treatments that have been prescribed by my/my childʼs physician.
2. Release pertinent medical information to my/my childʼs physician, referring agency, or insurer and others as may be required.
3. Request and obtain medical information from my/my childʼs physician and other health care professionals as necessary to provide quality therapy services.
Patient's Name*

First NameLast Name
Signature of Responsible Party*

Clear
Date Signed*

MonthDayYear
Date
Name of Responsible Party*

First NameLast Name
Email*
example@example.com
Phone Number*