Consent Form

Consent Form

This form must be completed by a parent, legal guardian or other person who has legal authority to act on behalf of the child.
Child Information
Name of Child

First NameLast Name
Date of Birth

DayMonthYear
Address

Street Address

Street Address Line 2

CityState

Post Code
Carer Information

It is essential that at least one parent/guardian details are completed
Name of Carer 1

First NameLast Name
Carer 1 E-mail Address
Carer 1 Mobile Number
I give permission for my child to be treated by Fusion Speech Therapy Services
I have received a copy of the fee schedule and cancellation policy and agree to the terms
I give permission for Fusion Speech Therapy Services to contact the following institutions for further information to assist in the assessment and treatment of my child

Other
Please name organisations listed above
PLEASE include preschool/school, doctor, paediatrician, Occupational therapist, physiotherapist, psychologist etc.
I DO NOT GIVE CONSENT FOR FUSION SPEECH THERAPY TO CONTACT ANY ORGANISATIONS
Please upload any recent reports that may be relevant

Browse Files
please upload any recent reports that we may not already have on file. e.g new NDIS plans, paediatrician reports, psychologists reports etc. Cancelof
Any other comments:
Signature
This form was completed by
Enter YOUR full name and relationship to child
Fusion Speech Therapy Services takes your privacy and security seriously. All information entered on this form is securely encrypted both in transit and at rest on our servers. Our security processes prevent unauthorised access.
Should be Empty:

Consent Form

Child Information

Carer Information