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Consent to Treat Minor Without the Presence of a Guardian/Parent
Thank you for your continued trust in our practice. Southbay Pain & Sports Medicine Acupuncture clinic must receive permission from a child's parent or legal guardian before providing treatment. This form gives us legal permission to treat your child in case you cannot accompany him/her to the clinic.
Consent to Treat
I authorize the clinical staff of S.P.A.S.M. Acupuncture to administer acupuncture and oriental medicine as deemed necessary to:
Child's printed name:
*
, who is my
*
.
Adult/Guardian's printed name
*
Adult/Guardian's signature
*
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