3. Consent to Treatment

Consent to Treatment

Fill this form out if you grant permission for another adult or themself to bring your child in for their therapy appointment and provide consent to care.
Patient Name*

First NameLast Name
Parent/Guardian Name*

First NameLast Name
I, the undersigned parent, give my permission for the following person to bring my child in for therapy and consent to care.
Person #1*

First NameLast Name
Relationship to patient*
Phone Number*
Please enter a valid phone number.
Person #2

First NameLast Name
Relationship to patient
Phone Number
Please enter a valid phone number.
Person #3

First NameLast Name
Relationship to patient
Phone Number
Please enter a valid phone number.
With my signature, I authorize that any name listed above, may be present for any therapy treatments effective from today's date for one year.

This Permission to Treat can only be revoked with my signature. I, the parent/guardian, understand that I must grant this permission annually.
Signature*
Your relation to the patient.

MotherFatherLegal Guardian
Should be Empty: