CONSENT FOR EXAMINATION: I understand that medical treatment may be necessary for the patient by My Kid's Doc Southfield, P.L.L.C., or his associates or assistants.
IĀ understand the examination procedures will be explained to me and I shall consent to the partial or complete examination. I understand that the examination results will be provided to me with recommendations. The responsibility for any follow-up examinations to check abnormalities found and treated lies with me and not with my physician. I hereby release my examiner from all responsibility in connection with this examination.
CONSENT FOR TREATMENT: I understand that medical treatment is necessary for the patient by My Kid's Doc Southfield, P.L.L.C., or his associates or assistants. I hereby consent to and authorize the administration of all diagnostic and therapeutic treatments that may be considered advisable or necessary in the judgment of the physician. No guarantee or assurance has been given by anyone as to the results that may be obtained by such treatments.
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.