Authorization to Treat In The Absence Of Parent Or Guardian

This authorization is for the following child/children

Please correct the errors described below.

Add Additional Child

I authorize the following person(s), other than the patient’s parents, to be present and to give consent for treatment by Jenny Welham, MD LLC.

Add Additional Name

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.

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