I hereby request and consent to Melo, Inc (Melo) to perform treatment and care for me as prescribed by a physician and/or recommended by an occupational therapist.

I understand and am informed that, as in the practice of medicine, occupational therapy may have some risks. I understand that I have the right to ask about these risks and have any questions answered about my child’s condition prior to treatment.
I acknowledge and agree that a parent or legal guardian must be present during each treatment session.
I consent and authorize Melo to administer treatment under the direction and supervision of a registered occupational therapist.
I understand that all service payments are due at the time of service, and that some therapy may not be covered by insurance. Melo will alert me as soon as possible about any portion of payment that is not covered, and I understand that payment is due immediately upon receipt of that information.
I have carefully read and fully understand this Informed Consent Form and have had the opportunity to discuss it with a member of Melo if I chose.

I agree to hold Melo harmless for claims or damages in connection with treatment. This is a contract between myself and Melo, and I understand that it is also a release of potential liability.

BY SUBMITTING THE INTAKE FORM, I AM AGREEING THAT I HAVE READ, UNDERSTOOD AND AGREE TO THE ITEMS CONTAINED IN THIS DOCUMENT.