By signing below, I hereby give my consent to OSR Physical Therapy to evaluate and treat the
following minor child:
Consent to Treat Minors
Consent to Treat Minor
Child’s Name _______________________________________________________________________
Child’s Date of Birth _________________________________________________________________
Relationship to Child _________________________________________________________________
PLEASE NOTE: OSR Physical Therapy strongly encourages parent or legal guardian participation in the Initial
Evaluation Appointment. In this appointment, the PT will establish the plan of care and review, in detail, the
necessary treatment components of the plan of care, including the frequency and duration of visits. It is important
for both the patient and the patient’s parent(s)/guardian(s) to understand the treatment being provided and to
provide informed consent to the specified treatment plan.
I understand the above noted description of the Initial Evaluation Appointment and recognize the importance of
attending this appointment with my minor child. If I am unable to attend, I will accept responsibility to contact the
evaluating physical therapist directly with any questions or concerns related to the evaluation or specified treatment.
Printed name of parent or legal guardian
_______________________________________________
Signature of parent or legal guardian ___________________________________________________
Date _______________________________________________________________________________
Phone number of parent or legal guardian ______________________________________________
Email address of parent or legal guardian _______________________________________________
Locations in:
ANTHEM | NORTH PHOENIX
PEORIA | GILBERT | SCOTTSDALE
GLENDALE | SUN CITY
w
ww.osrphysicaltherapy.com
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