Create SLP Services resquest

Patient (Person who will receive SLP Assessment/Treatment)
Patient's Date of Birth *
Format: 2017-12-15
Parental Authority: Father
Parental Authority: Mother
Parental Authority: Other

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I authorize the Speech and Language Pathologist to perform all required tests, examination and treatment procedures to complete their service mandate. I also authorize the Speech and Language Pathologist to use my email address to open my client account on this client portal, a SSL certificate secured documentation exchange internet tool accessed only with username and password.
I authorize the Speech and Language Pathologist to use speech, language, voice or academic skills information, as well as audio or video recordings, collected during assessment and treatment, for teaching or research purposes.

Would you like us to inform another professional (medical doctor, specialist, school personnel, etc.) about our assessment results and recommendations?

Please indicate above the name of the professional and how to reach them.

This request also is a consent to exchange information with mentioned professional.