CONSENT TO TREATMENT OF MINOR CHILD
I hereby authorize and whomever he designates as his assistants to administer chiropractic care as deemed necessary to my
(Indicate relationship of child)
(Printed name of child)
Dated at (City)
(State)
This day of
-
Month
-
Day
Year
Palmetto Spine
925 10th St E, unit 925
Palmetto, FL 34221
Phone: (941) 212-4410
Signed:
(parent or guardian)
Witnessed:
Submit
Should be Empty: