CONSENT TO TREAT A MINOR CHILD

I, (Parent/Guardian)

am the parent/legal guardian of (Minor)

I hereby authorize (check one or both)

Dr. Thomas Forbach

Dr. Rodney Smith

to provide chiropractic care and treatment to my minor child and whomever is designated as assistants to administer chiropractic care as deemed necessary to my child. I understand the scope of chiropractic services provided, and I acknowledge that I am fully informed about the risks and benefits.

Patient Name:

Date

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature: (parent or guardian)

Your information will be encrypted.