Motor Smart Kids Intake Form

Today's Date*
Date Format: MM slash DD slash YYYY
Child's First Name*
Child's Last Name*
Child's Date of Birth*
Date Format: MM slash DD slash YYYY
Age*
Sex*
Home Address*
Street Address Address Line 2 City State ZIP Code
Additional Address (if applicable)
Street Address Address Line 2 City State ZIP Code
Parent / Guardian #1
First Name*
Last Name*
Relationship to Child*
Home Phone*
Cell Phone
Work Phone
Fax Number
Email*
- I do not wish to be added to the newsletter mailing list
Preferred Method of Contact*
- Phone
- Text
- Email
Parent / Guardian #2
First Name
Last Name
Relationship to Child
Home Phone
Cell Phone
Work Phone
Fax Number
Email
- I do not wish to be added to the newsletter mailing list
Preferred Method of Contact
- Phone
- Text
- Email

CANCELLATION/NO SHOW POLICY*
As a courtesy to our therapists and our patients, please be sure to give at least 24-hours notice in the case that you are not able to make it to your scheduled appointment. In the event of a “no show” our patients will be billed 100% of the original charge. A less than one hour cancellation will be considered a “no show.” Every fifth less than 24-hour cancellation will result in a full session charge.
PHOTO/VIDEO RELEASE*
I authorize the use of videos/photos for the following (please check):
- Personal Use (i.e. home exercise programs, charting progress, etc.)
- Marketing Purposes (i.e. Web content, advertising, illustration, etc.) I grant to Starfish Therapies, its representatives and employees the right to take photographs of me and/or my child and my property in connection with the above identified subject. I authorize Starfish Therapies, its assigns and transferees to copyright, use and publish the same in print and/or electronically. I agree that Starfish Therapies may use such photographs of me and/or my child with or without my name and for any lawful purpose, including for example such purposes as publicity, illustration, advertising, Web content and therapist usage.
- No Photos/Videos
*
Form NTC 12-01*
VIEW & DOWNLOAD Form NTC 12-01 HERE

I acknowledge that Starfish Therapies has provided with a copy of Form NTC 12-01.

Parent / Guardian #1