Authorization to Treat:
There may be occasions when a parent (guardian) is not available to bring your child(ren) to our office. Your signature below allows us to provide care for your child(ren) in your absence. Otherwise, we need written permission prior to caring for your child(ren) for each occurrence.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
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