Consent or Coordinating Treatment (Facility only) - ShineLight

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Consent or Coordinating Treatment (Facility only)

Shine-Light, Inc.
Consumer*
First Last
Record No.
Parent/Guardian*
First Last
Date*
Date Format: MM slash DD slash YYYY
I do hereby grant Shine-light, Inc. the official authority to make necessary coordination for PSYCHIATRIC — MEDICAL — DENTAL — SURGICAL — EDUCATIONAL for my child, while under its care and residential responsibility.*

Consent or Coordinating Treatment (Facility only)

Shine-Light, Inc.