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NACH Form for Spread a Smile

[[[["field19","equal_to","Yes"]],[["show_fields","field20,field24,field23,field25,field21,field28,field27,field26,field22,field31,field30,field29"]],"and"],[[["field33","equal_to","Yes"]],[["show_fields","field35,field36,field37,field40,field41,field42,field38,field44,field33,field34,field45,field43"]],"and"]]
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NACH Patient Information
Gender
If relevant, please let us know if patient can be transfered from wheelchair, can they go up & down stairs. Any information will help us make their experience as pleasant as possible.
Parent/Guardian Information
Sibling Information
Siblings
Gender
Gender
Gender
Gender
Consent for us to contact parents of patients

Clic Sergent hereby agree to give Spread a Smile permission to contact parents of patients that they have come into contact with so that Spread a Smile can invite them to future patient & family events that they are planning.

Clic Sergent agree
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