Attestation Form
By typing your FULL NAME below, you are acknowledging that you have read and understood everything that was listed in the policies and procedures, consent, and getting started forms sent to you. You are also stating that you have had ample opportunities to ask as many questions as you can to ensure that you fully understand the nature of these services.

As a reminder, you have the right to pause, withdraw or deny services via telehealth at any point in time. Please be aware that with the nature of our scheduling, this may cause a disruption in services until we can find the schedule that can best fit your needs.
Email address *
Type your Full Name Below *
Your DOB *
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Child's Full Name *
Child's DOB *
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This form was created inside of Omega Center for Autism. Report Abuse