Patient Intake | Miraclesinmotionpt

Media release form

I hereby grant permission for Miracles in Motion Physical Therapy, LLC to use images of my child in the following ways which are designated below. Images will be used for marketing purposes for Miracles in Morton Physical therapy, LLC and to provide therapeutic education to other parents. Please indicate the following items that you consent to below by checking the boxes that apply.

If you provide consent for your child’s photos and videos to be used for any purpose above, please indicate how you would like your child displayed.

If you provide consent for your child’s photos /videos to be used for any purpose above please indicate how you would like your child to be identified

I agree to cancel any appointment within 24 hours. If cancellation is not made 24 hours prior to
the session I understand that I will be charged in full for that session. Please place your initials
in the above box.

Thanks for submitting!

Intake Questionnaire