Authorization for Consent of Care

Please correct the errors described below.

I hereby authorize Berkeley Pediatric Medical Group to examine and treat my minor

I understand that I may revoke this consent at any time,

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.

Email to: or fax to (510) 848-3109

Your information will be encrypted.