Remedy Speech Therapy

Patient's name *

Parent/Guardian *

Parent/guardian must complete this form if patient is under 18 yrs.

Use of Image/Video Consent

During the course of Orofacial Myofunctional Therapy treatment, it may be necessary for your child's therapist to use media, in the form of pictures and/or video, in order to provide proper therapy and document progress accordingly.

I give my consent for Remedy Speech Therapy to take and use pictures and/or video of the patient indicated above for treatment and progress monitoring purposes.

Signature of person completing form *

Date *

Image/Video Consent Form

Use of Image/Video Consent

Image/Video Consent Form