Permission to Treat a Minor

Patient Name:

Last First MI

DOB:

SSN:

Phone:

By signing below, you provide consent that your child may receive appropriate medical care and treatment, as deemed necessary by the providers at Advanced Allergy & Asthma Associates. You also understand that a parent or legal guardian must be present in the building at all times in order for your child to receive treatment, testing, and/or injections.

You authorize the following individuals to accompany your child at office visits or injections:

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DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Parent/Guardian:

Date

Print Name:

Relationship to Patient:

Your information will be encrypted.