Parental Consent Form

Parental Consent

* Indicates required field

Parent Name *

First

Last

Child Name: *

First

Last

As the parent or legal guardian of the child listed above, I give permission for her/him to have the following service(s) performed: *

By writing my name below, 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.

First and Last Name: *

Today's Date: *

By completing and submitting this form you agree to the terms and conditions.

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