Chiropractic Family & Sports Injury Center
801 FRANKLIN AVENUE
FRANKLIN LAKES, NJ 07417
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TELEPHONE: (201) 891-5599
FACSIMILE: (201) 891-8404
CONSENT TO TREAT A MINOR CHILD
The information I have given to this office pertaining to to____________________________(Child)
is truth full and complete to the best of my knowledge.
I authorize the doctors and staff of the Chiropractic Family & Sports Injury Center To administer such
procedures and treatment as they deem necessary to my (Son), (Daughter), (ward in my legal custody).
The doctors have no implied guarantee of cure.
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Parent or Guardian's signature Date
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Relationship to Minor Child
____________________________________ _____/_____/______
Witnessed By Date