To consent to any and all medical care and attention deemed necessary and appropriate for this minor by a healthcare provider licensed in the state of Nebraska. This consent includes, but is not limited to, medical and surgical intervention and elective as well as emergency care. This delegation shall be valid until I withdraw delegation of consent.
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.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.