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Consent or Coordinating Treatment (Facility only) - ShineLight
15828
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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.
*
Please choose one
I consent
I don't consent
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