Consent for Medical Treatment

(Mother’s Name or Legal Guardian)

& (Father’s Name or Legal Guardian)

authorize

Please list the best number to reach you in case we need to contact you for any reason:

Phone #:

Mother/Legal Guardian

Phone #:

Father/Legal Guardian

I allow Personal Care Pediatrics and its personnel to deliver medical services to my child (ren), listed below:

Add child

I (We) authorize the following people to bring my child (ren) in for treatment, and/or to contact in case of emergency:

Add authorized person

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 Name:

Signature:

Date:

Each individual must bring in a valid photo ID so we may properly identify them.
Please keep in mind this is for your family’s own safety.

Your information will be encrypted.