Gwen’s Speech Therapy        

“Communication is the Key”

        

Gwen Fowler-Berken, MS, CCC-SLP                P:828-371-3940

310 Terrell Road, Franklin, NC 28734                 F:828-369-7497

GA Lic #SLP008575        gwen@gwenspeech.com

NC Lic #8653        www.gwenspeech.com

EMERGENCY EVACUATION AND PICKUP AUTHORIZATION FORM

Client’s Name:

Age:

DOB:

Address:

Street

City/Town

State

Zip

Gender:

Male

Female

       

  Diagnosis, if any: 

FAMILY INFORMATION

Parent/Guardian:

Daytime Phone:

Mobile Phone:

Email:

Gwen Fowler-Berken, MS, CCC-SLP CAN RELEASE MY CHILD FROM THERAPY TO THE FOLLOWING INDIVIDUALS

Name ________________________________________   Relation ______________________

Name ________________________________________   Relation_______________________

Name ________________________________________  Relation _______________________

MEDICAL INFORMATION

Name of Primary Physician:

Physician Address:

Does the client take any prescription medications?  ☐ Yes     ☐ No

List:

Does the client take any over-the-counter medications on a regular basis? ☐ Yes  ☐ No

List:

Please list any medical, environmental, or seasonal allergies:

Please list any significant health problems or diet needs (i.e., asthma, diabetes, etc.):

In the event that the client needs medical attention off-site, what hospital would you prefer the client to be taken too?

Please read and sign below.  Your signature and initials indicate that you are in agreement with the policies described below.

Medical Emergency Policy

In the event that there is a medical emergency that requires the client to be immediately evacuated, every effort will be made to contact the parent/guardian first. Should the client require medical treatment off-site they will be sent to the hospital designated on this form as indicated by the parent/guardian. I understand that if a hospital is not otherwise indicated, that the client will be sent to the closest appropriate hospital as determined by emergency medical staff.  

_____Parent Initial

In the event of a medical emergency, you give your consent for Gwen Fowler-Berken, MS, CCC-SLP to disclose the above information to medical personnel as deemed necessary to assist in the care and medical treatment for this client.

_____Parent Initial

Parent signature

Date