Consent Forms

PROTOTYPE: These are demo consent acknowledgments only. Wording is marked UNSOURCED and has not been reviewed for clinical or legal use. No legally binding signatures are collected in this prototype.

Consent to Evaluate and Treat

I authorize Holistic Horizons Pediatric Therapy to evaluate and provide occupational therapy services to my child.

Authorization to Share Information

I authorize sharing of relevant information with my child's school, physicians, and other treating providers as needed for coordinated care.

Financial Responsibility

I understand that I am responsible for any co-pays, deductibles, or balances not covered by insurance.

HIPAA Notice of Privacy Practices

I acknowledge receipt of the Notice of Privacy Practices and understand how my child's health information may be used and disclosed.

Name for demo acknowledgment

By typing your name above, you acknowledge the consents checked above (demo only — not a legally binding signature).