Consent for Medical Treatment

Please correct the errors described below.


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

Mother/Legal Guardian
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.

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.