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: _____________________________________________________________________