West Valley Pediatrics Consent Form

Patient Name

DOB

The following individuals have my permission to bring my child to West Valley Pediatrics for medical care and treatment. I also authorize the same individuals to receive medical advice and information concerning my child, whether in office or over the phone. These individuals will also serve as emergency contacts for my child.

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I give my consent for the staff at West Valley Pediatrics to relay any imperative information by:

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Voicemail

Email (If registered with the patient portal)

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/Guardian Name Printed

Parent/Guardian Signature

Date

Your information will be encrypted.