PATIENT INFORMATION FOR MEDICAL RECORDS

OSTEOPATHIC HEALING HANDS, P.A. 2056 Sul Ross Houston, TX 77098 713-527-8499
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*PLEASE NOTE THAT WE DO NOT TAKE INSURANCE, THIS QUESTION IS ASKED FOR RECORD KEEPING PURPOSES.

CONSENT FOR TREATMENT

"I CERTIFY TO THE BEST OF MY KNOWLEDGE THAT THE ABOVE INFORMATION IS CORRECT. I HEREBY CONSENT TO MEDICAL AND OSTEOPATHIC TREATMENT FOR MYSELF OR MY CHILD/DEPENDENT."

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