CONSENT TO TREAT

I/We being the parents or legal guardians of the following minor:

Name (s) of Minor(s):

Date of Birth(s):

Do allow Kidology Pediatrics, PLLC permission to provide medical care and treatment to the above named.

I/We do hereby appoint the following (people other than Parent(s))

To bring my child(ren) to the appointment in my absence and if necessary, to act on my behalf in authorizing medical treatment for the above named minor(s).

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/Guardian Signature

Date

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