Consent to Treatment of a Minor

Please review the form below. For parents or legal guardians of a minor seeking chiropractic care

Consent to Treatment of a Minor

I hereby certify that I am the parent or legal guardian of the minor listed below. I consent to chiropractic care, including diagnostic procedures, x-rays, and physiotherapy treatment, as administered by the staff at Chiropractic Solutions of Georgia, LLC, doing business as Douglas Family Chiropractic.

This authorization becomes effective today: *

I understand I have the right to discontinue care for the above-named minor at any time.

Minor Full Name *

Date of Birth: *

Relationship to minor? *

Parent/Guardian Full Name *

Witness Full Name *

Parent / Guardian Signature *

Clear

Signature of Witness *

Clear

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