gladstonechiropractickc.com - Consent To Treat Minor

Consent To Treat Minor in the Absence of a Parent

A separate form must be submitted for each child.
As the parent or legal guardian, l,Parent Name hereby give consent to Dr. Karissa Rasmussen, D.C. to provide chiropractic care deemed necessary for the welfare of my child, Patient Name
born Patient’s Date of Birth , while said child is under her care.

This authorization is effective from the date of signature until revoked by the parent or guardian.
Signature of Parent or Legal Guardian
Date

MonthDayYear
Date
Witness
Date

MonthDayYear
Date
Should be Empty:

Consent To Treat Minor in the Absence of a Parent