Client Information Release Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Contact Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Date of Birth
*
-
Month
-
Day
Year
Date
Please check if you use any of the following.
*
Wheel Chair
Cane
Walker
Other
None of the above.
If you chose “other” please specify below. If not, you may skip this section.
If applicable, please list any chronic illnesses or impairments.
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Emergency Medical Authorization
In the event of an emergency, I authorize ReeVise Inc. staff to seek immediate medical care for my child.
*
I Agree.
Primary care physician’s name.
*
Primary care physician’s phone number.
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please list any medications dosages.
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Emergency Contact Info
1) Name
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to you
*
2)Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to you
Parent/Guardian Name *if client is under 18
First Name
Last Name
Parent/Guardian SIignaturrre
*
Date
-
Month
-
Day
Year
Date
Client Name
First Name
Last Name
Signature
*
Date
-
Month
-
Day
Year
Date
*Office personnel name (print), sign, and date below when printed.
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Continue
Should be Empty: