Release Form

1

Child's Name

First Name

Last Name

2

Child's Birthdate

Date

3

Legal Guardian's Name

First Name

Last Name

4

Email

example@example.com

5

Documents to be releasedCheck all that apply.

1. Speech, physical and occupational evaluations and treatment plans.

2. Swallow studies

3. Records/Reports from CME Inc.

6

I, the legal parent or guardian of the patient previously named, give CME Inc. permission to obtain from or give CME Inc. pertinent social, medical, or other information as listed below. I understand this information is confidential and will only be used for the benefit of this patient. I understand that this information may be subject to re-release by the recipient without knowledge or consent of CME Inc. and that CME Inc. is in no way responsible for this action. I further understand that this consent form is considered valid for the time period stated below or for the duration of this patient's enrollment, whichever is shortest, and that I may revoke this release anytime by requesting this release in writing and submitting it to this office or by requesting this form and signing below.

Clear

7

Release Valid for

90 days

120 days

1 year

8

Witness name

First Name

Last Name

9

Witness Signature

Clear