CONTRACT AGREEMENTAuthorization and Consent for Treatment of a Minor • May 30th, 2022
I, the undersigned, do hereby state that I have legal custody of the aforementioned Minor. I grant my authorization and consent for Center for Infant Tethered Oral Ties to administer occupational therapy treatments to the Minor. I agree to assume financial responsibility for all expenses of such care in accordance with Center for Infant Tethered Oral Ties' Payment Terms.
