I further authorize Elemental Medicine to release to appropriate agencies any information acquired during my or the above-named patient’s examination and treatment necessary to secure payment for services provided. Mother’s Signature: ___________________________________________________ Date: ___________ () I am SOLE custodial Parent Father’s Signature:____________________________________________________ Date:____________ ( ) I am SOLE custodial Parent *Payment is due at the time of the appointment* Unless Previous arrangements have been made
I further authorize Elemental Medicine to release to appropriate agencies any information acquired during my or the above-named patient’s examination and treatment necessary to secure payment for services provided. Mother’s Signature: ___________________________________________________ Date: ___________ () I am SOLE custodial Parent Father’s Signature:____________________________________________________ Date:____________ ( ) I am SOLE custodial Parent *Payment is due at the time of the appointment* Unless Previous arrangements have been made