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I/we understand that we can revoke this consent at any time. Names of individual s authorized to acquire routine and emergency services for my child Full Name Date Witness PTA-005-070912 Rev. 06-16. Treatment Consent for Minor Child or Patient with Guardianship Patient s Name Date of Birth Age Street Address City State Zip Code Parent/Legal Guardian 1 Relationship Home Phone Sex Cell Phone Please provide a copy of parent s or legal guardian s Photo ID and Insurance Card s Photo ID or...
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What is city amp state?
City & state refers to the location where the individual or business is located.
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Individuals or businesses that are operating in a specific city or state may be required to file city & state taxes.
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