Pediatricadvanced_Consent_to_eval

Consent to Evaluation and Treatment
Name*

Child's First NameChild's Last Name
Date of Birth*

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Type a question
Consent to Treatment and Assumption of Risk
I acknowledge and agree to have my child (or the child under my care), receive evaluation and treatment services for the discipline stated above from Pediatric Advanced Therapy. I acknowledge that there is some risk inherent in the use of the therapy equipment and I agree to assume such risk and indemnify and hold Pediatric Advanced Therapy and its staff, harmless from any and all losses and claims for any injuries or other damages occurring to myself, my child or our belongings.
Parent/Guardian's name*
Parent/Guardian signature*

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Consent to Evaluation and Treatment