Consent for Allergy Injections for Unaccompanied Minors

give my consent to Allergy Associates of Western Michigan, P.C. to give my minor child allergy injections in my absence.

In the event of a reaction, I give my consent for any treatment deemed necessary and appropriate for my child.

Name of Patient:

Patient date of birth:

DISCLAIMER: 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.

Signature of Parent/Guardian

Date:

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