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 firstname.lastname@example.org
NC Lic #8653 www.gwenspeech.com
Diagnosis, if any:
Name ________________________________________ Relation ______________________
Name ________________________________________ Relation_______________________
Name ________________________________________ Relation _______________________
Name of Primary Physician:
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.
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.