pediatric chiropractic health questionnaire · pediatric chiropractic health questionnaire welcome...
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![Page 1: Pediatric Chiropractic Health Questionnaire · Pediatric Chiropractic Health Questionnaire Welcome to our Office! Please answer the following questions: I agree to assume responsibility](https://reader035.vdocuments.mx/reader035/viewer/2022071218/605046c0ffaff43c6b2e35eb/html5/thumbnails/1.jpg)
Pediatric Chiropractic Health QuestionnaireWelcome to our Office!
Please answer the following questions:
I agree to assume responsibility for any charges created by the chiropractic care, and give consent for my child to beexamined and/or treated by Dr. Paolo and his staff.
Parental Signature ____________________________________________________________ Date ____________________________________________
![Page 2: Pediatric Chiropractic Health Questionnaire · Pediatric Chiropractic Health Questionnaire Welcome to our Office! Please answer the following questions: I agree to assume responsibility](https://reader035.vdocuments.mx/reader035/viewer/2022071218/605046c0ffaff43c6b2e35eb/html5/thumbnails/2.jpg)
![Page 3: Pediatric Chiropractic Health Questionnaire · Pediatric Chiropractic Health Questionnaire Welcome to our Office! Please answer the following questions: I agree to assume responsibility](https://reader035.vdocuments.mx/reader035/viewer/2022071218/605046c0ffaff43c6b2e35eb/html5/thumbnails/3.jpg)
Orlando Advance Chiropractic
Dr. Paolo Wong1507 S. Hiawassee Rd Ste 214Orlando, FL 32835
Phone: (407) 233-4749
Consent to Treat a Minor Child
Date ______________________________
I Hereby Authorize:
The above named doctor, and whomever he or she may designate asassistants, to administer the required care as deemed necessary to my(indicate relationship of child) _______________________________ (Name ofChild) _________________________________.
Signed: __________________________________________________________________________Parent or guardian
Witnessed: _____________________________________________________________________