By signing this form, I hereby request and consent to UpWords Speech Therapy Services, LLC to perform screenings, evaluations, and/or treatment as prescribed by a physician and/or recommended by a speech-language pathologist.
I acknowledge and agree that a parent or legal guardian must accompany my child and be present during each treatment session.
I have reviewed the HIPAA Notice and understand that I am able to ask questions regarding the notice at any time.
I understand that a payment card, kept on file, is required for all services rendered by UpWords Speech Therapy Services, LLC.
I have carefully read and fully understand this consent form.