AUTHORIZATION FOR RELEASE OF INFORMATION

AUTHORIZATION FOR RELEASE OF INFORMATION
Anniel Nagler, MSPT
Pediatric Physical Therapist
Phone: (954) 648-7819
Fax: (954) 231-0799
FUNdamental Therapy Inc
4106 North 48th Avenue
Hollywood FL 33021
anniel@funtherapyinc.com
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Child's Name:*

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I give my permission to my child's Physician/Agency/Organization to contact Anniel Nagler, MSPT with Fundamental Therapy Inc. regarding all care for the purpose of providing the appropriate services and continuity of care.
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