Rebecca Costa

  
 Dr Dennis Campbell, MD 
 Thibadaux - 726 North Acadia Road 
 orthoLA 
 Laplace - 465 Belle Terre Boulevard 
 Raceland - 141 Twin Oaks Drive 
 Houma - 180 Corporate Drive 
 Orthopaedic Sports Medicine, 
 Joint and Hand Specialists 
 CONSENT FOR 
 THERAPY CARE AND TREATMENT 
 I, the undersigned, do herby agree and give my consent for ortho LA to provide physical 
 therapy and or occupational therapy care and treatment considered necessary in treating 
 my physical condition. 
 Patient 
 Printed Name: Rebecca Costa
 Nadine Buggage 
 14-09-18
 Signature of Patient/Guardiah 
 Date 
 CONSENT FOR TREATMENT OF A MINOR: As a parent and/or legal guardian, I 
 authorize Ortho-LA to treat the minor patient named in the attached forms. 
 Signature of Patient/Guardian 
 Date 
 Post Office Box 28 Thibodaux LA 70302//Tel:451-902-9714//Fax:116-221-9298//www.ortho-la.com
