Pediatric Consent Form

(We) the parent (s) or legal guardian (s) authorize the individual (s) named below to act in my (our) behalf with the full authority to grant permission for any medical treatment, including administration of immunizations if recommended, or surgical procedure that is in the best interest of the above named child in the opinion of the Canyon Pediatric providers, licensed to practice in the State of Arizona. In addition, the provider is hereby authorized in an emergent situation to perform whatever acts that in his/her professional opinion are in the best interest of the above-mentioned child. I understand that the provider may request to contact the parent/guardian prior to providing medical treatment even though this consent is presented. Since medicine and surgery are not an exact science, it is acknowledged that no results can be guaranteed. I understand that as parent(s) or legal guardian(s) that I am financially responsible for all care received as a result of this consent.

ADULTS THAT MAY SIGN FOR MEDICAL TREATMENT IN MY (OUR) ABSENCE:
(Authorized individuals should also be listed in Privacy Practices)

AUTHORIZED BY: (Both parents signature preferred, but not required)

By signing below, I certify that I am the legal parent or guardian of the child identified above and am acting within my authority in signing this Pediatric Consent form.

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

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

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

ANY CHANGES TO THIS CONSENT MUST BE MADE IN PERSON AT THE PHYSICIANS OFFICE.