THEOBALD FAMILY CHIROPRACTIC

CONSENT FOR CARE OF MINOR

As parent/guardian of _______________________________________, I do hereby
authorize and request Dr. David Theobald to perform any necessary examiniations, x-rays,
and Chiropractic Care.

____________________________________         ______________________
Signature of Parent/Guardian                                     Date

___________________________________         _______________________
Print name of Parent/Guardian                                  Date

___________________________________         _______________________
Witness                                                                   Date

DATE:         _______________

NAME:         __________________________________________________________

ADDRESS:  __________________________________________________________

By my signature on this form, I, do hereby state that to the best of my knowledge, I am not pregnant,
neither suspected or confirmed at this time.

Patient Signature: ______________________________________________________