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.

Your information will be encrypted.