Authorization for Consent of Care

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

Child

Birthdate

When he/she is accompanied by

Relationship to patient

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.

Signature

Date

Email to: Frontdesk@berkeleypediatrics.com or fax to (510) 848-3109

Email address

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