Therapies 4 Kids - REGISTER ONLINE NOW

Untitled Document

REGISTRATION FORM

Clients Name:

Date of Birth:

Sex:

Parent/Guardian:

Address:

Country

State:

Zip:

Email Address:

Home Phone:

Medical Information:

Primary Diagnosis:

Secondary Diagnosis:

Precautions: (swallowing, apnea, Seizures, Blood Pressure, Diabetes, etc.)

Clients Weight:

LBS

Height:

Surgical History: ( Fractures, Casting, Tendon releases, Eye repair, Subluxation,etc.)

Medical Interventions: (Shunts, G-tubes, Botox Injections, Baclofen Pump, etc.)

Medical Equip: (oxygen, trach tube, suction pump, etc.)

Current Medications:

Current Skills: (rolling, reaching, crawling, sitting, etc.)

Adaptive Equip: (walker, wheelchair, stroller, AFOs, Hand Splints, etc.)

Things your child Enjoys:

Session of Interest:

AM PM

What month(s) are you interested in attending the program:

Will you be participating in The Hyperbaric Oxygen Therapy:

Yes No

Development of Milestones: Please write the approximate age of your child when the following milestones were achieved. If your child has not yet achieved the milestones, please indicate that information as well.

Attained Head Control:		Rolled:		Sat:
Crawled:				Walked:

Thank you for your interest in the Therapies 4 Kids Program. We hope to see you soon.

Clicking "Submit" will send the above information.

PLEASE FILL OUT THE REGISTRATION FORM BELOW
IF YOU ARE INTERESTED
IN OUR INTENSIVE PEDIATRIC PROGRAM
WITH SUIT THERAPY.

There is NO OBLIGATION when you fill out this form.

Once we receive your registration you will be contacted in order
to discuss whether our program is appropriate for your child
at this time. Scheduling can also be discussed.

You will also receive our FREE information package
which contains our Informational Video and
Brochure about our program.

1. Completely fill out and submit back to us. Please be as thorough as possible, so that we have a better understanding of your child's needs. This form can be mailed to you upon request.

2. Upon approval for our program, you will need to submit a written report regarding recent hip x-rays (within the last 6 months) specifically an A/P view of your child's hips to rule out hip subluxation or dislocation and a "prescription" for therapy from any one of your physicians that should read: Therapy 5x's per week for 3 weeks / 4 hours per day for Intensive Program.