General Acknowledgement of Forms
I hereby acknowledge and agree that I had read all of the forms and documents provided to me in connection with evaluation and treatment provided by Peak Pediatrics LLC.
I understand the meaning and intent of the provided forms and agree to all content included.
I have been given an opportunity to ask questions about the provided forms and all questions I’ve asked have been answered to my satisfaction by Peak Pediatrics LLC.
Print Name of Client
Relationship to Client
Date
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Month
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Day
Year
Signature of Client
Submit
Should be Empty: