Consent For Medical Care Treatment

Please correct the errors described below.

In presenting my son/daughter for diagnosis and treatment.

I/We hereby voluntarily consent to the rendering of such care, including diagnostic procedures and medical treatment for the well being of said Child/Children.

I/We have read this forma and I/We certify that I/We understand its' contents.

In my / our absence to arrange for routine or emergency medical care and treatment necessary to preserve the health of my / Our child/children.

I / We acknowledge that I am / We are responsible for all reasonable charges in connection with the care and treatment of said Child/Children rendered during my / our absence by the doctors of Associated Pediatricians, LLC.

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.

IN CASE OF EMERGENCY I CAN BE REACHED AT:

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