Consent For Treatment
Child's First Name
Child's Last Name
Child's Date Of Birth
Medicaid ID (if applicable)
I,
hereby authorize Sunshine Center Pediatric Therapy to evaluate and/or treate for the following services:
Speech Therapy
Occupational Therapy
Physical Therapy
Hearing Screening
Counseling
Relationship To Child
Date Form Submitted
Parent/Guardian Signature
( Draw your Signature below in the box with your finger or mouse )
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+ For Administrative Purpose Only
Group Representative Signature
( Draw your Signature below in the box with your finger or mouse )
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Submit