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IF PATIENT IS A MINOR (LESS THAN 18 YEARS OLD) Age of minor: Name of person completing form:Please Printify Parent or Legal Guardian is unavailable to accompany minor to appointment, please list authorized
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How to fill out i am aware that
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Provide your personal information as requested on the form, such as your full name, date of birth, and contact details.
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Clearly state the specific matter or issue that you are aware of.
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Sign and date the form to acknowledge that you are aware of the stated matter.
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