Patient Information

(not living with you)

Referral and Injury Information

(Please note that Medicare patients must provide a presciption from a doctor to receive therapy)

Additional Care

Responsible Party Information

(Required if patient is a minor)

Consent to Treatment of Minor Child

I , am the parent/legal guardian of who is currently a minor, whose date of birth is . I hereby authorize Hand & Orthopedic Physical Therapy Specialists to provide physical/occupational services as may be considered necessary or appropriate under the circumstances. I further understand that once my child reaches the age of majority, my consent for treatment is no longer required.

Surgical / Health History