This form is for clients seeking medical advice based on an initial review of medical history and interview during a virtual screening visit. Any formal evaluation and/or treatment may be indicated after physician referral. By completing this form you are giving consent to release medical and personal information for the purpose of this therapy screening. All medical advice and /or business conducted through the Chad G Ortho OT website will be under Guerrero Rehabilitation, LLC. Your medical and personal information will not be shared with anyone other than Chad Guerrero and Guerrero Rehabilitation, LLC.