PLAYTIME CHILDREN'S THERAPIES | SHERWOOD, ARKANSAS

	Patient Referral ------------------------ Patient Referral Form
	Attendance Policy ------------------------ Attendance Policy.doc Attendance Policy.pdf
	Privacy Policy Consent ------------------------ Private Policy Consent.doc Private Policy Consent.pdf
	Patient Information ------------------------ Patient Information.doc Patient Information.pdf
	Authorization for Treatment ------------------------ Authorization Form.doc Authorization Form.pdf
	Call Back Request ------------------------ Use this form to request a call from Playtime

Please fill in the information below to the best of your ability.


Therapy Requested:	Physical Therapy Occupational Therapy Speech Therapy
Language:
Client Information	-------------------------------------
Patient's Name:
Date of Birth:	MM/DD/YY
Age:
Sex:	Male Female
Names of Parents/Guardian:
Home Address of Parents/Guardian:
Home Phone Number of Parents/Guardian:
Work Number of Parents/Guardian:
Email Address of Parents/Guardian:
Child Referred By:
Physician Information	-------------------------------------
Primary Care Physician:
Physician Phone Number:
Physician Fax Number:
Clinic Address:
Medical History	-------------------------------------
Diagnosis:
Is the child currently on medication:	No Yes
Has the child been evaluated before:	No Yes
Date of last evaluation:	MM/DD/YY
Private Insurance	-------------------------------------
Insurance company:
Name of insured:
Insurance ID#:
Insurance Company Phone Number:
Additional Information	-------------------------------------
Any additional information or instructions should go here:
We accept Medicaid, file with many insurance companies, and offer family-friendly rates.