The Children's Clinic Consent for Patient Treatment
Please correct the errors described below.
# 3 Fairwind Street
P.O. Box EE 17887
Tel: (242) 323-0266 | Fax: (242) 698-6703
CONSENT FOR PATIENT TREATMENT
I hereby authorize the healthcare professionals at THE CHILDREN’S CLINIC to provide such medical care and to administer such treatment, including immunizations, as deemed necessary or advisable to the named patient each time he / she presents to THE CHILDREN’S CLINIC.
GUARANTOR OF ACCOUNT
I hereby agree to pay in full ALL charges to THE CHILDREN’S CLINIC at the time services are rendered. I also agree to pay any amount not covered by Primary or Secondary Insurance within 30 days of receipt of statement.
I confirm that I have read and understand the above statement
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(Responsible for Account)
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