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 ____________________________________________
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: _____________________________________________________________________
