Skagit Pediatrics, LLP | 2101 Little Mountain Ln. Mount Vernon, WA 98274 (360) 428-2622 Fax (360) 428-3941
Please fill out this form if your child will be coming for a visit, treatment, or procedure, accompanied by someone other than a parent or legal guardian. This agreement will stay in effect for one year from the date of signature below unless revoked in writing by a parent or legal guardian.
I approve the above-named person to seek health care for my minor child listed above. I know that I am financially responsible for all health care fees incurred by my child during these visits.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
I approve the above-named person to seek health care for the minor child listed above. Financial duty for health care fees owed during these visits is outlined in the foster care records.
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