As per Texas Family Code Chapter 32.001, I consent for medical treatment of the above named minor.
Date(s) of consent to treat form effective:
(Note: you may allow up to 1 year for this form to be effective, one day only for verbal consent)
I give permission for Coppell Pediatric Associates, PA to provide medical treatment to the minor named above.
The consent is effective for the dates listed above.
If consent is verbal, it is witnessed by 2 staff members, acknowledged by signatures below.
I declare under penalty of perjury that the above information is true and correct.
*Please note, we must have a signed consent for well child exams AND vaccines. The physician will need to see and speak with both patient and parent on day of well child exam, and parent must be at well child exam to give written consent for immunizations.
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.
Staff Members x2 have simultaneously, verbally witnessed consent of parent listed above.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use: