OK Can Do Kids - Intake Form

Agreements
By checking the boxes below, I agree that I have read and understand the Payment Agreement and Conditions*

I understand that I am responsible for all charges not covered by insurance/Medicaid-Medicare.I authorize the release of any medical information necessary to process this claim.I authorize release of any medical information from other professionals necessary for initial evaluation or continued treatment.I authorize payment of medical benefits to undersigned provider for services.I understand that I will be responsible to pay a $35.00 fee if I fail to show up for an appointment OR cancellation notice is not given at least 24 hours in advance of scheduled appointments.I understand payment is due upon receipt of statement and I agree to pay a $35 late fee if payment is not made within 30 days of statement date, unless other arrangements have been made.
Photo authorization

Yes - I authorize permission for photos to be taken to use in the clinic and/or for publications.No - I Do Not authorize permission for photos to be taken to use in the clinic and/or for publications.
Signature

Clear
Introduce Your Child
Current Diagnosis
Other Persons Living In Child's Household
Allergies You Child Has
Primary Goals For Child*