Medium

Available on

Apple Android Windows

Child Speech Therapy Intake and Release Form Mobile App

This Child Speech Therapy Release Form is a comprehensive health history app with an emphasis in the area of child speech therapy. Includes basic patient information, insurance details and heath history. This app can be easily customized to fit your specific needs.

  • Lendlease
  • The Cooperative
  • PG&E
  • oxy
  • Red Bull
  • Mirvac

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Take a peek inside the Child Speech Therapy Intake and Release Form Mobile App

Included Features

Our App Builder gives you the power to easily add and remove the ones you want. {{controller.show_all ? 'See included features.' : 'See more features.'}}

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Included Fields

Customize to add, remove, or edit any of the fields below.

  • Ico textbox

    Patient's Name

  • Ico date

    Date of Birth

  • Ico textbox

    Parent/Guardian Name

  • Ico checkbox

    I authorize the release of information about the above patient, from the list below.

  • Ico textbox

    Primary Care Physician Name

  • Ico textbox

    Title

  • Ico textbox

    Organization

  • Ico textbox

    Phone

  • Ico textbox

    Email

  • Ico textbox

    Insurance Company Name

  • Ico textbox

    Title

  • Ico textbox

    Organization

  • Ico textbox

    Phone

  • Ico textbox

    Email

  • Ico textbox

    School District/Teacher Name

  • Ico textbox

    Title

  • Ico textbox

    Organization

  • Ico textbox

    Phone

  • Ico textbox

    Email

  • Ico textbox

    Other Name

  • Ico textbox

    Title

  • Ico textbox

    Organization

  • Ico textbox

    Phone

  • Ico textbox

    Email

  • Ico statictext

    Information to be released — goals/objectives, progress, observations, recommendations.

  • Ico date

    It expires on

  • Ico statictext

    or no more than one year from the date of my signature.

  • Ico statictext

    I also understand that I may change this authorization at any time.

  • ...and More!

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