Treatment Authorization | EBS Children's Therapy of Georgia

I, (Parent/Guardian named below) authorize Chandler Speech and Language Services, LLC to evaluate and provide the recommended speech and language therapy to the patient named below.

Therapy/treatment is contingent upon the results of the evaluation and the recommendations of the speech and language pathologist.

Prior to evaluation a prescription must be obtained.
Parent/Guardian*
First Last
Patient's Name*
First Last
Patient of Parent/Guardian Signature*
Relationship to Patient*
Today's Date*
Date Format: MM slash DD slash YYYY