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Nombre del cliente:

Fecha de nacimiento del cliente:

La persona que firma este formulario es: Cliente Padre/Tutor

Nombre de la persona que firma este formulario:

Doy fe de que he revisado y comprendido los formularios de este documento, los cuales se indican a continuación:

Acepto la información contenida en cada formulario al que adjunto mis iniciales, certificación o firma.

FIRMA:

Cliente o padre/tutor:	Fecha:

Si corresponde:

Personal de MNCarePartner:

Fecha:

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

Draw your signature with your mouse, tablet or smartphone Clear

I agree that I am and I agree this is a legal representation of my signature for all purposes just the same as a pen-and-paper signature

I agree that I am and I understand this is a legal representation of my signature

Timestamp

Audit

January 30, 2022 11:54 pm CDT

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