Schedule Appointment

Schedule an Appointment

To schedule an appointment, please complete the form below and our office manager will reach out to you for scheduling
Name*

First NameMiddle NameLast Name
Sex*
Date of Birth*

MonthDayYear
Parent/Guardian Name*

First NameLast Name
Contact Number:*

Area CodePhone Number
E-mail*
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Are you requesting:*

Occupational TherapyPhysical TherapyBoth Occupational and Physical TherapyUnsure
Do you wish to have your child seen at school if the school permits it?*

YesNo
If yes, what school does your child attend?
Referring Physician *
Phone Number*

Area CodePhone Number
Primary Care Physician *
Phone Number*

Area CodePhone Number
Specialist
Phone Number

Area CodePhone Number
Taking any medications, currently?*

YesNo
If yes, please list it here
Medical Diagnosis and History *
Reason For Referral/Concerns *
Primary Health Insurance Company *
Member ID *
Group Number
Policy Holder Name *
Policy Holder Date of Birth *
Secondary Health Insurance Company
Secondary Member ID
Secondary Group Number
Secondary Policy Holder Name
Secondary Policy Holder Date of Birth
I, hereby, give consent for Little Feet Therapy to render skilled physical/occupational therapyservices for my child. I am aware that all therapy services will be provided by a licensedphysical or occupational therapist and that treatment is based on medical necessity.*

Clear
Date

MonthDayYear
Date
I was notified of Little Feet Therapy’s Notice of Privacy Practices (HIPAA) and if I would like a copy of these PrivacyPractices, I will request them by contacting by calling 704-931-8022.*

Clear
Date

MonthDayYear
Date
I consent to the release of information by doctors, psychologists, counselors, teachers/school, other therapy providers; to include, but not limited to occupational, physical, speech, music, behavioral therapy, and all other facilities where my child has been treated and would hold information pertinent to their therapy plan of care to Little Feet Therapy. I also authorize Little Feet Pediatric Therapy. I also authorize Little Feet Therapy to release any medical or pertinent information to my child's growth and development to their doctors, psychologists, counselors, therapists, school,teachers, care/service coordinator, and the family members listed below: (You may revoke your authorization in writing at any time; this release is valid for three years from the date signed below.)*
Signature*

Clear
Date

MonthDayYear
Date
I give consent and authorization for Little Feet Therapy to verify. I understand that verification of benefits does not guarantee payment by the insurance company. I authorize Little Feet Therapy to submit claims to my insurance company and for my insurance company to release payment on my behalf to Little Feet Therapy. I understand that I am responsible for insurance deductibles, copays, coinsurance and amounts not covered by any insurance or payment provider. Payment will be made according to invoice. This invoice will be sent from Little Feet Therapy via email on a monthly basis. For payments made 30 days past the due date; a 25% late fee will be added and the account will be sent to a collections agency.*

Clear
Date

MonthDayYear
Date
I consent and give permission to you and those acting under your authority to photograph/video and use the likeness of my child in connection with Little Feet Therapy including but not limited to posts on social media including Facebook and Instagram, printed marketing material and website posts.By signing below I certify that I am the parent or legal guardian of the child above, a minor. I release Little Feet Therapy, its parent, affiliates, officers, directors, agents and employees, and those acting under its authority, from all debts, claims and liabilities of any kind arising out of or in connection with the use and publication of the photograph/ likeness referred to above. The undersigned does hereby agree to hold Little Feet Therapy, its parent, affiliates, officers, directors, agents, and employees, and those acting under its authority, against loss from any claim, action, or demand that may be brought at any time by the above-named minor or by anyone acting on the minor's behalf for the purpose of enforcing a claim for damages on account of the use and publication of the minor's likeness and photograph.*

YesNo
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Schedule an Appointment