Form – Authorization to Treat a Minor NameThis field is for validation purposes and should be left unchanged. Please complete the following form to authorize Dr. Jen Sims, DC or an authorized associate physician or specialist to treat a minor at Blue Sky Health and Wellness. Name of the Signatory(Required)I, hereby acknowledge that I have read and understand the policies of Blue Sky Health and Wellness. Phone(Required)Email(Required) Your Child's Full Name*(Required)Enter Child's NameParent's eSignature(Required)PLEASE SIGN HERE FOR YOUR E-SIGNATURE.Date Signed(Required) MM slash DD slash YYYY Please do not submit any Protected Health Information (PHI).CAPTCHA Please do not submit any Protected Health Information (PHI).
