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Minor Consent

Upon submitting this form, I give permission to the chiropractors and assistants with Gallatin Chiropractic Clinic to treat my child.

It is understood that this consent is given in advance of any specific diagnosis or treatment and allows the chiropractors/assistants to diagnose and treat the child even when the parent or guardian is not present.

*If Power of Attorney is required to show legal guardianship, you will be required to show Power of Attorney paperwork.

This Consent is effective until withdrawn in writing by the child’s parent/guardian or until child turns 18 years of age.

Upon submitting this form, I hereby declare that all information provided in this form is true, correct, and complete to the best of my knowledge and belief.

Date
Day
Month
Year

Please do not submit any Protected Health Information (PHI).

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(615) 451-3400

Address

210 Baber PK Dr W, Suite 120
Gallatin, TN 37066

Reclaim Your Comfort & Confidence

© 2025 by Go Chiro Pro

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