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TALK OF THE TOWN THERAPY
PEDIATRIC THERAPY & EARLY INTERVENTION SERVICES
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Therapy Referral
Patient Name
DOB
Parent Name
Phone*
Speech Therapy
Phsical Therapy
Occupational Therapy
I certify that I am aware of this referral and I give Talk of the Town Speech Therapy, LLC permission to evaluate and provide services to my child, permission to bill my child’s health insurance company, and permission to discuss and disclose my child’s healthcare documents with his/her doctor, case worker, or healthcare professional.
Date
Initials
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