Payment Consent Form | Beyond-Limits

Language assistance services and appropriate auxiliary aids and services, including information in accessible formats, are available to you free of charge. Call 770-917-5737 (TTY: 711) or speak to your provider.

Questions marked * are required.

Child’s Information

Child’s Name:

First Name:

Last Name:

Goes by:

DOB:

Please enter a date that isn't in the future.

Gender

Male

Female

Please choose an answer.

Diagnosis and Services Received:

Payment Consent

PURPOSE: The purpose of this form is to obtain your consent to securely store your preferred method of payment for your child’s health appointments. By signing this consent form, you authorize Beyond Limits Pediatric Therapy Center to charge your card at the time of your child’s weekly appointments. Upon request, a receipt can be emailed to you by the close of business following your child’s session.

I agree to leave my payment method on file at Beyond Limits Pediatric Therapy Center and to pay for the services rendered for my child in full at the time of service.

Parent First Name

Parents Name:

First Name:

Last Name:

Date:

Please enter a date that isn't in the future.

Parent/Guardian Signature