PEDIATRIC PATIENT INTRODUCTION

AUTHORIZATION FOR CARE OF MINOR
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)
SIGNED:.

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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.
SIGNED

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