Telecommunication Form

Informed Consent of Telecommunication for the Speech and Language Therapy

I (fill in your name)

Consent to receive speech and language therapy through telecommunication for (fill in childs name below)

Text

I have read and understand the modified HIPPA Policies outlined in Barbara Anslow-Myers SLP letter dated March 30, 2020 regarding COVID-19. I understand I have the right to refuse telecommunication at any time.

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