Attendance

Attendance

Office
I certify that the patient is in attendance for their session today.
Date of Session*

MonthDayYear
Date
Do you have new insurance or a new card?*

YesNo
Do you have multiple appointments in your family today?*

YesNo
Please sign in for all appointments.
Patient Name*

First NameLast Name
Patient Name

First NameLast Name
Patient Name

First NameLast Name
Name

First NameLast Name
New Questions for 2023

Please make sure to answer these questions for the 2023 Calendar year
Have you received a copy of the HIPAA policy and the Office policies for 2023? They were emailed to you and can be found on our website at www.speechandmore.com/faq*

YesNo
Do you agree to the Office policies?*

YesNo
If no, please answer why below.
Signature*

Clear
Should be Empty:

New Questions for 2023