Speech Language Pathologists, Nancy L. Foreman and Associates, SPEECH is the WINDOW and MIRROR of the MIND

Slow or stagnant speech development

Consistently hoarse voice

Consent to Treat/Release Information

 

** Required Fields

 

Date:      
** I, (Legal Guardian): 
** Email Address: 
authorize Nancy L. Foreman & Associates to evaluate:
** Patient Name: 
and/or provide Speech and Language Therapy.
 
I, (Name): 
authorize Nancy Foreman and Associates to release and obtain clinical information regarding:
to and from the following persons or agencies:
Name 1: 
Address 1: 
Name 2: 
Adress 2: 
 
In consideration of treatment and educational purposes, I give consent that sound recordings,
records, and/or photographs may be used as deemed helpful by the staff. I understand that the
information may be discussed with other Speech Pathologists within the office and/or Patient
Physician regarding evaluation and/or treatment goal strategies.
 
This form has been fully explained to me/us, and I/we understand the contents.
 
Legal Guardian or Patient Signature: 
Date: 

 

 

 

**  


security code
Enter Security Code:

 
Please be patient while form submits.
 
PLEASE BE PATIENT WHILE FORM SUBMITS.