Help Me Grow Utah801-691-5322[email protected]148 W 100 NProvo, Utah 84601
Weeks Premature (put "0" if not premature)
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I have read the provided information about the Ages & Stages questionnaires, and I wish to have my child participate in the online screening program. I will fill out the questionnaire about my child's development and promptly submit the completed questionnaire through this Family Access online questionnaire completion system.
I am the parent or legal guardian of this child with authority to make healthcare decisions for my child. By clicking submit, I agree to allow data entered through this electronic form to be stored in a secure database for my provider to review.
If I choose not to submit this and share my child’s screening data as stated above, I may request a paper screening option from my child’s provider.
I understand that signing this authorization is voluntary. I understand this authorization will expire upon my child's 18th birthday. I understand that I may revoke this authorization at any time and the revocation does not apply to any action that has taken place prior to the date I revoke this authorization. To revoke this authorization, I must make a request in writing and send it to: [email protected]. Subject Line: REVOCATION.
Note: By clicking "Submit", you are agreeing to both our Family Access End User License Agreement and any other consent or authorization information outlined on this page.