AUTHORIZATION TO TREAT MINOR PATIENT IN ABSENCE OF PARENT/GUARDIAN

Name of minor patient:

Date of Birth:

I certify that I am the parent and/or legal guardian of

Please check all that apply:

I authorize

to bring my child to office visits.

I authorize the minor child named above to come alone to office visits.

I consent to the examination and/or treatment of my child.

Parent/Legal Guardian Contact Information:

Home Address:

City:

State:

Zip:

Cell Phone:

Fax:

I reserve the right to revoke this authorization at any time by notifying VFASA in writing.

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.

Parent/Guardian Name:

Date:

Witness Name:

Date:

Your information will be encrypted.