Rehabilitation Chiropractic dba Aaaah...Wellness

CONSENT TO TREAT A MINOR FORM

Arizona law requires consent from a parent/legal guardian for healthcare of a minor.
I, (print name)*

First NameLast Name
the parent/legal guardian of
(minors name)*

First NameLast Name
do hereby consent to any medical care conducted here at Aaaah… Wellness, by its doctors and/or staff to provide healthcare to my son/daughter, including, but not limited to, diagnostic examinations, radiological testing, laboratory testing, and all treatment deemed necessary.

I further understand that once my child reaches the age of 18, my consent for treatment is no longer required.
Signature of Parent/Legal Guardian*

Clear
Date*

MonthDayYear
Date
Signature of Witness*

Clear
Date*

MonthDayYear
Date
Should be Empty: