I HEREBY AUTHORIZE THIS OFFICE AND ITS DOCTOR(S) TO ADMINISTER CARE AS THEY SO DEEM NECESSARY TO MY SON/DAUGHTER/WARD (UPON APPROVAL OF PARENT OR GUARDIAN)
I REALIZE THAT IAM RESPONSIBLE FOR ALL FEES CHARGED BY THIS OFFICE AND IAGREE TO PAY FOR ALL SERVICES PROVIDED.
X-RAYS REMAIN THE PROPERTY OF TH ISOFFICE.