I hereby acknowledge and confirm that prior to signing this document and prior to undergoing any treatment:
I am at least sixteen (16) years old and I have read and am in agreement with the foregoing statements and have had the opportunity to discuss the same with Dr. Sabrina Giustra, N.D. I hereby authorize and consent to such treatment by Dr. Sabrina Giustra, B.Sc., N.D. as she considers necessary or desirable, subject to any additional instructions or modifications that I may provide/authorize from time to time.
OR
I am the of the patient who is under the age of sixteen years, I confirm that I am legally authorized to grant consent to have the patient treated by Dr. Sabrina Giustra, B.Sc., N.D.
I have read and am in agreement with the foregoing statements and have had the opportunity to discuss the same with Dr. Sabrina Giustra, N. D. as she considers necessary or desirable, subject to any additional instructions or modifications that I may provide/authorize from time to time. I have read and agree to these terms
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