I consent to Primary Therapy Source to provide occupational, physical, and/or speech therapy for my child.  I understand and agree that, (regardless of my insurance status), that I am ultimately responsible for the balance of my account for any services rendered. I have read all the information contained on this form and have completed the above measures. I certify this information is true and correct to the best of my knowledge. I will notify you of any changes in my health status or the above information.
I agree to notify Primary Therapy source if I have previously seen another physical, speech or occupational therapist or if I see another therapist during my treatment with Primary Therapy Source. If I do not notify Primary Therapy Source, I agree to pay for any unauthorized services that are not paid by my insurance. I authorize Primary Therapy Source to release my records to their billing service, my insurance company and my physician. I understand that these records will be held in strict confidence and will not be released to any unauthorized person. I authorize payment of medical benefits to undersigned physical or supplier of services rendered.
Cancellations and No-shows given less than 8 business hours are assessed a $15.00 fee for each occurrence.

I hereby authorize Primary Therapy Source, to release any information acquired in the course of my child's examinations and/or treatments to my insurance company, physician/other care providers, school.