Patient Name *

First Name

Last Name

Responsible Party *

First Name

Last Name

Phone *

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Terms: *

I hereby authorize Northeast Orthotics and Prosthetics to order a cranial remolding orthosis for my child. I agree to be financially responsible for the service once this form is signed. I understand the cranial remolding orthosis (helmet) is a custom fabricated item and may not be returned. If I cancel the order I will be financially responsible for the fabrication of this item. I understand that I will be responsible for the service if my insurance denies the claim.

I acknowledge and agree to all Terms as outlined above

Responsible Party Digital Signature *

Please type your name below, which will be used in place of a physical signature to this form

First Name

Last Name