Parental Consent for the Treatment of a Minor

Child's Name

Date

Allergies to Medications

Current Medications

Any Concerns you want addressed today

Any conditions we need to know about

In the event that we need to contact you during today's visit

Parent/Guardian Name

Contact Phone Number

I hereby, consent to the rendering of care, for my child, including immunizations, diagnostic or routine tests and medical treatment by Medical Center Pediatrics Physician or their designees in my absence.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Parent/Guardian

Date

Your information will be encrypted.