4906 Wisconsin Ave., NW
Washington DC 20016
202-486-7388
laura@thekidscommunicationcenter.com
CONSENT FOR SERVICES
As the parent/guardian, I give my permission to The Kids’ Communication Center, LLC to exchange information about the patient whose name and date of birth are specified below, with the following physicians, programs, or other persons:
I also give permission for The Kids’ Communication Center, LLC to provide information, treatment, and consultative services to the patient. I understand that the fees for services provided are due upon receipt of the invoice.
I acknowledge that I have read and agree to the terms above. By typing my name, I am electronically signing this document.