Parental Consent for Minors
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As the parent or legal guardian of (minor’s name), *
I give permission for her/him to have the following services performed: *
I confirm that I have read and understand all information on the applicable forms for this treatment or service, and accept responsibility on my child’s behalf for any disclosures or liability described on those forms. I agree to supervise any home care procedures that are recommended as a result of the treatment. *
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Full name of parent or guardian: *
Signature of Guardian: *
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