Add additonal child's information
Emergency Contact Other Than Parent/Guardian:
Besides parent/guardian(s) listed above, who has permission to bring your child(ren) to Medical Center Pediatrics and consent to treatment?
By signing below, I give my consent for my child(ren) listed to receive treatment by Medical Center Pediatrics, PLLCBy 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.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2024 Hush Communications Canada Inc.