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Chiropractic Family & Sports Injury Center |
801 FRANKLIN AVENUE |
FRANKLIN LAKES, NJ 07417 |
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TELEPHONE: (201) 891-5599 |
FACSIMILE: (201) 891-8404 |
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CONSENT TO TREAT A MINOR CHILD |
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The information I have given to this office pertaining to to____________________________(Child) |
is truth full and complete to the best of my knowledge. |
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I authorize the doctors and staff of the Chiropractic Family & Sports Injury Center To administer such |
procedures and treatment as they deem necessary to my (Son), (Daughter), (ward in my legal custody). |
The doctors have no implied guarantee of cure. |
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Parent or Guardian's signature |
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Relationship to Minor Child |
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Witnessed By |
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