JUST FOR KIDS PEDIATRICS, PLLC

Non-Parent Consent Form (Optional)

Please correct the errors described below.

AUTHORIZATION FOR NON-PARENT TO CONSENT TO CARE

Patient’s Full Name

I authorize the following persons to seek medical care for the above listed child(ren) and they must present their ID at every visit:

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This authorization will remain in force until revoked in writing by me. I hereby attest that I have the legal authority to delegate my authority to consent for care, and that no legal agreement prevents me from delegating authority. DISCLAIMER: By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

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