Altitude Chiropractic LLC

Altitude Chiropractic LLC 6921 E. Garth Circle Palmer, AK 99645 Ph: (907) 745-5444 Fax: (907) 745-3780 AltitudechiropracticAk.com

Patient Name:______

Patient Age:______Date of Birth:___/___/___

I , hereby authorize Altitude Chiropractic LLC and Dr. August Manelick DC to evaluate, diagnose and treat my child listed above. I understand that this consent is valid until it is revoked by me or the attending Chiropractic Physician. This authorization may be revoked at anytime by giving written notice of my desire to the acting Chiropractic Physician for Altitude Chiropractic LLC.

I also allow the DC staff to discuss the minor child’s medical information, to include financials, with other medical providers and staff within the HIPPA guidelines if referrals are necessary.

As of this date, I have the legal right to select and authorize health care services for the minor child named above.

______Childs Name (Printed) Signature Date

______Legal Parent/Guardian Name (Printed) Signature Date

______Relationship to Minor Patient

Note: The treatment of minors requires the prior consent of a parent or legal guardian. In (Alaska, a person is considered to have arrived at majority at the age of 18. Sec. 25.20.010)