Consent & Release of Information v2 Child Name*DOB* Date Format: MM slash DD slash YYYY Is there another child to add?YesNoSecond Child Name*Second Child DOB* Date Format: MM slash DD slash YYYY Parent/Guardian Name*Is there a second Parent/Guardian to add?*YesNoParent/Guardian #2 Name*I have read the Welcome Letter.*Read Welcome Letter (opens in new tab/window).YesNoI 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.*YesNoI have read and understand the Consent & Release terms. I understand that missed sessions will be invoiced from the credit card on file, delinquent accounts will be charged to credit card on file, and credit card fees will apply to any invoices.*YesNoI understand that unpaid invoices will be charged to the credit card on file with processing fees added.*YesNoSignature Parent/Guardian #1:*Signature Parent/Guardian #2:*CAPTCHAGet a PDF copy of this form emailed to you. Enter Email Confirm Email Let us know which email to send a PDF of this form to.CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.
