Consent & Release of Information Child NameParent NameI understand that Advantage Speech Therapy Services will BILL MY INSURANCE COMPANY but that any unpaid balances are my responsibility whether denied, partially paid, or not covered by my insurance company. I also understand that all balances owed are to be paid within two weeks of receipt of invoice. There is a minimum of a $30 charge for any returned checks.*YESNOI understand that I may be INVOICED FOR A CO-PAY, TRAVEL OR AS A PRIVATE PAY CLIENT for services in full. I understand that all payments must be paid within 2 weeks of receipt of invoice.*YESNOI give consent to have Advantage Speech Therapy PROVIDE SPEECH THERAPY SERVICES to my child.*YESNOI give consent for my child’s PICTURE/VIDEO to be taken (no names) to be used for social medial and marketing materials.*YESNOI agree to allow Advantage Speech Services to OBTAIN, RELEASE, DISCUSS AND/OR EXCHANGE PERTINENT INFORMATION about my child with other therapists and/or medical professionals in order to best treat my child.*YESNOSignature:*NameThis field is for validation purposes and should be left unchanged. Save and Continue Later This iframe contains the logic required to handle Ajax powered Gravity Forms.