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800-832-9419 Get Started

Home
About
Services
- Center-Based Services
- Home-Based Therapy
Insurance
- New Patients
Location
Gallery
- Resources
Career
Contact Us

800-832-9419 Get Started

Food Authorization Form

Child's Name

Child's Date of Birth

List ALL known food allergies:

Free Text

We are not a peanut, tree nut or allergen-free clinic. We do try to take precautions to ensure that your child does not ingest one of their known allergens. To best accommodate their needs, please provide a list of items they can and cannot eat.

Please list any food items they cannot ingest:

New Field

I authorize Compass BDC to provide food/snack items.

I do NOT authorize Compass BDC to provide food/snack items.

Signature

Today's Date

Printed Name

Preferred Number

Diaper/Bathroom Assistance Authorization Form

Diaper/Bathroom Assistance Authorization Form

Child's Name

Child's Date of Birth

Child's Age

I authorize Compass staff to:

Change diaper/pull-ups

Apply ointment

Assist with bathroom training/wiping

Changing clothes

Apply ointment topically:

When rash is present

With every diaper change

Other

If other, please specify:

Allergies to Latex:

Yes

No

Diaper/Pull-up Brand Provided:

Ointment Brand Provided:

Further Instructions:

Allergies to Latex:

Yes

No

Field label

I authorize Compass BDC staff to change my child’s diaper/take them to the bathroom, while in the clinic receiving treatment. I agree to supply an extra change of clothes, wipes, diapers, ointments, and any other supplies needed. I understand it is my responsibility to make Compass staff aware of any allergies or sensitivities related to diapers, ointments, or anything else of that nature. Compass will contact you if you we out of diapers. Staff will use gloves during the diaper change.

I do not authorize

I do NOT authorize Compass BDC staff to change my child’s diaper/take them to the bathroom.

Signature

Today's Date

Printed Name

Preferred Number

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Contact Us Today

Have Questions? Feel free to come to us with any questions or concerns.

Our Locations

Valdosta, GA - Clinic 1

3121 N. Oak St Ext Valdosta, GA 31602

800-832-9419 Ext. 1

officev@compassaid.com

Valdosta, GA - Clinic 2

2935 N Ashley St Suite 120 Valdosta, GA 31602

800-832-9419 Ext. 1

officev@compassaid.com

Lakeland, GA Clinic

32 West Main St. Lakeland, Georgia 31635

800-832-9419 Ext 2

officel@compassaid.com

Warner Robins, GA

225 Smithville Church Rd, Suite 1100 Warner Robins, GA 31088 USA

800-832-9419 Ext. 4

officew@compassaid.com

Thomasville, GA

602 Victoria Place, Suite A Thomasville, GA 31792 USA

800-832-9419 Ext. 3

officet@compassaid.com

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