Child's name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Mobile Phone *

(###)

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Alternative Phone

(###)

###

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*

I, the parent/guardian of the named child, consent to Physiotherapy and/or Occupational Therapy assessment and treatment of my child by therapist(s) working on behalf of Kids’ Therapy Works.

*

I have had the assessment explained fully. I have also had the opportunity to ask any questions I may have prior to assessment.

*

I am aware I am liable for any fees as set out in Kids’ Therapy Works Terms & Conditions. These can be accessed online at www.kidstherapy.works

*

I am aware that full payment of agreed fees is payable on the day of treatment. Post-treatment payment will only be accepted if therapy is being funded by a third party, i.e. charity, or following successful completion of a direct debit mandate.

*

I am aware that if full fees are not paid 14 days prior to the commencement of blocks of treatment, then all appointments booked will be cancelled/withdrawn.

*

I am aware I may withdraw consent for further assessment and treatment at any time.

*

I am aware of the following appointment cancellation fee: Under 48 hours notice will be liable for 100% of the session cost plus travel. Blocks of intensive therapy require 4 weeks’ notice of cancellation. Intensive blocks are non-refundable.

I consent for videos and photographs to be taken as part of my child’s therapy program. Photos/videos are securely stored. Photos/videos may be taken on a mobile phone device.

I consent for videos and photographs taken as part of my child’s therapy program. to be used in Social Media posts or on our web site www.kidstherapy.works for promotional purposes.

I consent for Kids’ Therapy Works to share appropriate confidential information with other agencies when working in the interests of the child.

Your name *

First Name

Last Name

*

I have read and fully understood the terms for submitting this form by electronic signature as stated below under "Electronic Signature Consent and Acknowledgement"

Date

MM

DD

YYYY