CONSENT FOR MEDICAL CARE
I give consent for to bring my child (children),
to Dr. Deborah Ungerleider for medical evaluation and treatment.
Parent/Legal Guardian Name & Signature
City, State and Zip Code
To print out this form, click on the link below.
Deborah L. Ungerleider, MD, LLC
44 Godwin Ave Suite 100
Midland Park, NJ 07432
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