The Children's Clinic Consent for Patient Treatment

# 3 Fairwind Street
P.O. Box EE 17887
Nassau, Bahamas
Tel: (242) 323-0266 | Fax: (242) 698-6703
Email: paedsclinic@yahoo.com

Signature of Patient:

Date of Birth:

CONSENT FOR PATIENT TREATMENT

AUTHORIZATION

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

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 / Relative or Guardian Name:

(Responsible for Account)

Date:

P.O. Box:

E-Mail:

Work Phone:

Home Phone:

Mobile Phone:

Alternate Contact:

Witnessed by THE CHILDREN’S CLINIC Administration:

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