(not living with you)
I , am the parent/legal guardian of who is currently
a minor, whose date of birth is . I hereby authorize Hand & Orthopedic Physical Therapy Specialists to
provide physical/occupational services as may be considered necessary or appropriate under the circumstances. I further understand that once my child reaches the age of majority, my consent for treatment is no longer required.
A parent or legal guardian must be present at first visit to sign Consent to Treatment of Minor Child Form