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.
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Associated Pediatricians, LLC
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