New Patient Forms
Please download the form, fill in the form on your computer and email it back to us at firstname.lastname@example.org
If you have any questions, feel free to contact us at (773) 467-5669 or email@example.com
PATIENT DATA BASe
This form is to provide the office with names and addresses, physicians and basic patient information for our data base.
NEW CLIENT INFORMATION
This form is for the evaluating therapist to have basic information about the child’s history and current function.
AUTHORIZATION of RELEASE
This form allows City Kids to communicate with insurance companies and physicians regarding the client’s intervention.
/Social Media Release
This form allows or disallows permission to use photos for social media, education and celebration of each child.
ATTENDANCE POLICY AGREEMENT FORM
This form explains attendance expectations and charges for missed appointments.