• OT WELLNESS

    OT WELLNESS

  • Optimize Today's Wellness Therapy Solutions INC.

  • Doral Office 9600 NW 25 ST. SuitePH Daral, FL 33172 Homestead Office 13420 SV/ 314" St. Suite 169 Homestead, FL 33033 Fax: (786) 8003836

    General Information / InformaciónGeneral

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  • Has any other specialist seen the client? If yes, indicate the type of specialist and when the child was seen/ ¿Ha sido visto el niño por otro

    especialista? En caso afirmativo, indique la especialidad y cuándo el niño fue visto:

  • Prenatal and Birth History / Historia clínica durante el embarazo y nacimiento

  • Developmental History / Historia clínica del desarrollo

    How old was your child when / ¿Qué edad tenía el niño cuando?:

  • Medical History / Historia clínica

    Has the child had any of the following illnesses? / ¿Ha tenido el niño alguna de las siguientes enfermedades?:

  • Throat infection / Infección de la garganta Ear infection. How many? / Infección de los oídos. ¿Cuántas?

  • Dehydratation/ Deshidratación Epilepsy / Epilepsia High fever / Fiebre alta Tonsil infection / Infección de anginas

  • Mumps / Paperas Bladder problems / Problemas de la vejiga. Kidney problems / Problemas de los riñones Pneumonia / Neumonia.

  • Educational History / Historia educacional

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  • OT WELLNESS

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  • This permission is allowed while the above name child is at Optimize Today's Wellness Therapy Solutions office, school, daycare center, home, family member's home/any area that the undersigned leaves the child during the time of the child's appointment with Optimize Today's Wellness Therapy Solutions Inc., concerning the care and treatment of the above named child.

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  • NOTICE OF PRIVACY ACKNOWLEDGEMENT

  • I have read and understood the notice of Privacy Practices.

    By Signing the following, I hereby agree to have listed both Primary and Secondary insurances (If applicable) Failure to comply, may result in charges and penalties not covered by the insurance.

    Al firmar la siguiente, acepto haber enumerado los seguros primarios y Secundarios (si corres ponde) incumplimiento puede resultar en cargos y multas no cubiertos por el seguro.

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  • Optimize Today's Wellness Therapy Solutions INC.

    Doral office 9600 NW 25 ST. Suite PI Doral FL 33,72 Homestead Office

    13420 SV/ 314 St. Suite 169 Homesterd, FL 33033

  • As well as, outside individuals or entities that have a need to access this information to perform functions on behalf of Optimize Today's Wellness Therapy Solutions, INC. and its affiliates (for example, insurers, legal advisors, data storage companies We recognize that some of those who receive protected health information may not have to satisfy the privacy requirements that we do and may re-disclose it, so we share this information only if necessary and we use all reasonable efforts to request that those who receive it take steps to protect your privacy.

    How long will protected health information about me be used or shared with others? There is no scheduled date for your health information that is being used or shared for this research to be destroyed, because research is an ongoing process, during which information may be analyzed and re-analyzed in light of scientific and medical advances, or reviewed for quality assurance, oversight or other purposes.

    Statement of privacy rights: - You have the rights to withdraw your permission for the researchers and participating with entities to use or share your protected health information. We will not be able to withdraw all of the information that already has been used or shared with others to carry out related activities such as oversight, or that is needed to ensure the quality of the study. If you want to withdraw your permission, you must do so in writing by contacting Optimize Today's Wellness Therapy Solutions, INC. - You have the right to choose not to sign this form. If you decide not to sign, you cannot participate in this research study. However, refusing to sign will not affect your present or future care and will not cause any penalty or loss of benefits to which you are otherwise entitled. - You have the right to request access to your protected health information that is used or shared during your treatment or payment for your treatment, but you may access this information only after the study is completed. - You have the right to receive a copy of this form after you have signed it.

    I have read this form and all my questions about this form have been answered. By signing below, / acknowledge that / have read and accept

  • Yo confirmo haber recibido información de la notificación de normas de privacidad del profesional mencionadas anteriormente y que he

    tenido la oportunidad de leerlo y entenderlo. Este consentimiento es requerido por la ley gubernamental.

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