Permission To Evaluate And Provide Physical Therapy Services

Permission To Evaluate And Provide Physical Therapy Services
Parent/Guardian Name *

First Name Last Name
Child's Name *
Date of Birth *

Month Day Year
Please complete this form to grant permission for Raleigh Therapy Services, Inc. to evaluate your child’s gross motor skills as well as provide necessary treatment as needed.

I {parentguardianName}, authorize Raleigh Therapy Services, Inc. to evaluate and provide the recommended physical therapy to {childsName}.

Therapy/treatment is contingent upon the results of the evaluation and the impending recommendations of the responsible physical therapist.
Insurance Provider
Policy/Subscriber ID Number
Group Number
By signing this you authorize Raleigh Therapy Services, Inc. to bill the patient’s insurance as well as accept payment for any services rendered.
Signature of Parent/Guardian *
Is treatment required as the results of an employment injury, auto accident or other accident? *

Yes No
If yes, please explain
Should be Empty: