Release of Health Information

Creative Kids Therapy Phone: 870-336-0220 Fax 870-558-5637

Name

Patient Relationship

Email

Phone

Address

Patient First and Last name

Patient Date of Birth * required

Therapy Company Name & Phone or Fax Number

Records to be Released * Required

Occupational Therapy Evaluation / Plan of Care

Physical Therapy Evaluation / Plan of Care

Speech/Language Evaluation / Plan of Care

School Records / IEP

Other / Medical Records

I agree to this form as electronic consent

Select a date * required

For the Purpose of ... * Required

Coordinating care with other professionals

Providing continuity of services

Updating therapeutic progress

Other

Please Explain

I certify that I am the parent/legal guardian of the above mentioned patient and I hereby authorize communication between Creative Kids Therapy & the company listed above.

Thanks for submitting!

Creative Therapy

Phone: 870-336-0220 Fax: 870-558-5637

1218 Stone St Suite 140
Jonesboro, AR 72401

Email Us!

Privacy Policy

Notice of Privacy Practices

bottom of page