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AUTHORISE TO CONSENT TO MEDICAL TREATMENT OF CHILD
Information of Child
____________________, male, born 28 May 2022 at ________________________ and residing at __________________________________________
Name: ____________________Address: ________________________Phone Number: ____________________Secondary Phone: ____________________Email: ____________________
IN WITNESS WHEREOF, I hereunto sign my name at ____________________, this ________ day of ________________, ________.
_____________________________________________________
NOTARY ACKNOWLEDGEMENT
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