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Services to Minors Your signature indicates that both of the minor s parents/guardians are aware of the minor receiving services. D. for services rendered. I understand that I am responsible for the balance on my account for any professional services rendered. Date Signature of patient or authorized person This Office is HIPAA Compliant Please Read and Sign Other Side 4362 Northlake Boulevard Suite 108 Palm Beach Gardens Florida 33410 561 694-1887 Fax 561 626-2131 For Your Information...
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