Client Health Care Practitioner and Release Form

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Dear parent(s)/Legal Guardian(s);

ISLP and staff would like to thank you for your continued trust in our services and want to assure you that we're continuing to provide the best services possible for your child.

The person who's invested in your child since birth is your child's "Pediatrician" and he/she is your best source of referrals! Being a multidisciplinary team we strongly believe in "team work" which means we would like to be in touch with your pediatrician to ensure the best quality of continued care!

Please kindly provide the name of your child's Pediatrician and/or any other health care professionals who provides services for your child with their contact information and provide it to our office.

Thank you again for being the best parent(s) and advocate for your child!

Email *

Client Health Care Practitioners

Pediatrician:

Audiologist:

Occupational Therapist:

ENT:

Speech Therapist:

Neurologist:

Physical Therapist:

ABA Therapist:

Infant Stim Therapist:

Dentist:

Psychologist:

Gastrointestinal Doctor (GI doctor):

Optometrist/Opthamologist:

Orthopedist:

Developmental Pediatrician:

Dietitian/Nutritionist:

Any other health care professionals working with the client, please list:

I hereby give my consent for all relevant information regarding

Client Name:

Client Email:

Please note: this Release applies to all accounts/contracts associated with this client at the time of request to be exchanged by Innovative Speech & Language Pathology, Inc and the authorized receiving personal.

By signing below, I/we understand that my client information will be released as outlined above.

This authorization terminates one year from the date of this Letter of Authorization or earlier if I/we provide written revocation to my/our advisor, the account(s) close or the relationship with Innovative Speech & Language Pathology, Inc. terminates. Upon my/our authorization my/our advisor may provide information to a third party, but the request does not obligate the advisor to provide follow-up or ongoing information or materials.

Client/Authorized Signer: *

Date: *

YYYY

Submit

Clear form

Never submit passwords through Google Forms.

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms