• Permission To Evaluate And Provide Physical Therapy Services

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  • 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.

  • By signing this you authorize Raleigh Therapy Services, Inc. to bill the patient’s insurance as well as accept payment for any services rendered.

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