germantownchiro.com - CONSENT TO TREAT MINOR PATIENT WITHOUT PARENT PRESENT

CONSENT TO TREAT MINOR PATIENT WITHOUT PARENT PRESENT
In order for us to treat a minor without his/her parent/legal guardian present, the parent/legal guardian should complete this form.

I, Print Name am the parent/legal guardian of Print Name currently a minor, whose date of birth is Date .

I authorize Dr. Sarah Murrow or Dr. Andrew Stone of Germantown Chiropractic to provide medical care to my son/daughter in my absence, including but not limited to, diagnostic examination, diagnostic procedures, and necessary treatment by Germantown Chiropractic.

I authorize Type a label to sign any medical forms necessary for my son/daughter in case of my absence.

This consent will remain in effect until the patient reaches the age of eighteen unless revoked in writing to Germantown Chiropractic. I further understand that one my child reaches the age of majority, my consent for treatment is not longer required.

By signing this, I acknowledge I have read and agree to this consent and that any questions I had prior to signing were answered by Dr. Sarah Murrow of Germantown Chiropractic.
Signature

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Date

MonthDayYear
Date
Relationship to Patient
Witness
Emergency Numbers:
Home Phone Number:
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Cell Phone Number:
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Work Phone Number:
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