Patient's First and Last Name
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First Name
Last Name
Name of Responsible Party
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First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Today's Date
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Month
-
Day
Year
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Signature Required
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Signature of Patient/Parent/Guardian - If signatory is under 21, the parent or legal guardian must also sign to signify agreement.
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