Consent for Services "*" indicates required fields Parent's Name* First Last Child's Name* First Last Email* Phone*Consent for Services* By checking this box I agree to the Consent for Services Policy.I authorize Christina D’Arco, is association with Heroes of All Sizes Pediatric Therapy to render appropriate observation, screening, evaluation an/or therapy services to the client named below in accordance with state and federal laws. I understand that care will be provided by a qualified, licensed, and trained health professional. I recognize, agree and understand that I have the right to refuse treatment or terminate services at any time by Heroes of All Sizes Pediatric Therapy in writing. In addition, Heroes of All Sizes Pediatric Therapy may terminate services by notifying me in writing.NameThis field is for validation purposes and should be left unchanged.
