New Patient Intake Form

CONSENT FOR EVALUATION AND TREATMENT:

I voluntarily authorize Grow With Us Therapy, LLC, and its employees to provide occupational therapy evaluation and treatment to the Patient in the home, school or office setting. I am aware that treatment may include the following:

• Physical evaluation by an occupational therapist
• Participation in a physical therapeutic exercise regimen
• Physical agent modality treatment per recommendation by therapist

NOTICE OF PRIVACY PRACTICES:

I have read and acknowledged the Notice of Privacy Practices by the Florida Department of Health as well as Grow With Us Therapy, LLC’s privacy practices and have been informed of my rights as a Patient/legal guardian.

CONSENT FOR RELEASE OF PRIVATE INFORMATION:

I hereby authorize the release of the Patient’s health information to the Referring doctor, Pediatrician, Teacher, Insurance company, and Organization that may provide ongoing therapeutic or daily living services to the Patient.

CONSENT FOR PHOTOGRAPHY AND VIDEOTAPING:

I voluntarily consent to photographs and videos being taken of the Patient during evaluation or treatment. I also voluntarily consent to the use of such photographs and videos by Grow With Us Therapy, LLC, for educational, research and marketing purposes.

CANCELLATION POLICY:

If a session needs to be canceled, 24 hours notice of cancelation prior to session is requested. If no prior contact is made before the time of the session, a $30 fee will be charged. If your child becomes ill on the day of the scheduled session, please contact the therapist as soon as possible to cancel or reschedule your session.

GUARANTEE OF PAYMENT:

I agree to pay the service cost listed below. I understand that I will be billed at the end of the month and I have 7 business days to pay the balance before a $25.00 per day late fee will be charged. Grow With Us Therapy, LLC accepts all major credit cards, cash or checks. Please make all checks payable to Grow With Us Therapy, LLC. Grow With Us Therapy, LLC is a Gardiner approved provider.

Grow With Us Therapy, LLC does not accept insurance payment. I understand that I will be given an invoice/receipt with the appropriate CPT codes in order to submit to an insurance company on my own, should I choose to do so.

ASSUMPTION OF RISK:

I acknowledge and agree, and Grow With Us Therapy, LLC has explained to me, that:

• The activities used during treatment provided by Grow With Us Therapy, LLC and the occupational therapy activities and equipment used as a part of that treatment have inherent risks, dangers, and hazards and such exists in the use of any equipment and participation in these activities.
• Participation in such activities and/or use of such equipment may result in injury or illness including, but not limited to bodily injury, disease, strains, fractures, partial and/or total paralysis, death or other ailments that could cause serious disability.
• The aforementioned risks and dangers may be caused by the negligence of the agents or employees of Grow With Us Therapy, LLC, the negligence of the participants, the negligence of others, accidents, breaches of contract, or other causes.

By participation in these activities and for use of equipment, I hereby assume all risks and dangers and all responsibility for any losses and/or damages whether caused in whole or in part by the negligence or the conduct of the agents or employees of Grow With Us Therapy, LLC, or by any other person.

I, on behalf of myself, my personal representatives and my heirs, hereby voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify Grow With Us Therapy, LLC and its agents, employees, and assigns from any and all claims, actions or losses for bodily injury, property damage, wrongful death, loss of services or otherwise which may arise out of my use of any equipment or participation in these activities.

I specifically understand that I am releasing, discharging, and waiving any and all claims or causes of action that I may have presently or in the future for the negligent acts or other conduct by the agents or employees of Grow With Us Therapy, LLC.

I HAVE READ THE ABOVE WAIVER AND RELEASE AND BY SIGNING IT I ACKNOWLEDGE AND AGREE THAT IT IS MY INTENTION TO EXEMPT, RELIEVE, AND HOLD HARMLESS GROW WITH US THERAPY, LLC FROM ALL LIABILITY CLAIMS OR CAUSES OF ACTION FOR PERSONAL INJURY, PROPERTY DAMAGE OR WRONGFUL DEATH CAUSED BY NEGLIGENCE OR ANY OTHER CAUSE.

PATIENT STATEMENT OF AGREEMENT:

My signature below signifies that I have read, understand, and agree to the policies, procedures and terms provided on this form by Grow With Us Therapy, LLC and I intend to comply with them to the best of my ability.

Grow With Us Therapy, LLC reserves the right to terminate this contract and discontinue services at any time in its absolute sole discretion.