I authorize the Southern Therapy Solutions staff to:
Change Diaper/Pull-UpsApply OintmentAssist with bathroom training/wipingChanging clothes

If you authorize us to apply topical ointment, in which scenarios:
When rash is presentWith every diaper change

Allergies to latex?
YesNo

Diaper/Pull-Up brand provided:
Ointment brand provided:
Further Instructions:

I do authorize Southern Therapy Solutions 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's my responsibility to make STS staff aware of any allergies or sensitivities related to diapers, ointments, or anything else of that nature. Southern Therapy Solutions staff will contact the parent/guardian if the child is out of diapers. Staff will use gloves during the diaper changing process.

-- or --

I do NOT authorize Southern Therapy Solutions staff to change my child’s diaper/take them to the bathroom.

Please select one
I do authorize the aboveI do NOT authorize the above

Parent/Caregiver Signature