Consent to Treat Form

Patient Name” *

I HAVE READ AND UNDERSTAND THE CONSENT TO TREAT AND CHOOSE TO BE TREATED BY A LICENSED MEDICAL VOLUNTEER, UNDERSTANDING THE LIMITATIONS ON THE RECOVERY OF DAMAGES DESCRIBED ABOVE FOR: *

Patient

I am the Parent/Guardian for the patient: I am the Parent/Guardian for the patient:

Patient or Parent/Guardian Signature Acknowledgment: *

Clear

Date Acknowledgment Signed: *

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