CONSENT FOR MEDICAL TREATMENT OF MINOR

Please correct the errors described below.

COMPLETE SECTION A OR B

SECTION A: consent by parent/managing conservator/guardian or other adult

Complete this section ONLY if the parent/managing conservator/guardian CANNOT BE CONTACTED. The person having the right to consent to medical treatment for the above minor (parent/managing conservator/guardian) cannot be contacted and has not given notice to the contrary. As per Texas Family Code Chapter 32.001, I may consent for medical treatment of the above named minor.

I give permission for Bay Area Obstetrics & Gynecology, P.A. to provide confidential medical treatment, including contraceptive services, to the minor named above. This consent begins on the date below and remains in effect unless revoked in writing. I declare under penalty of perjury that the above information is true and correct.

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.

SECTION B: consent by minor client

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I declare under penalty of perjury that the above information is true and correct.

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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