In accordance with Iowa Code Chapter 599, it is the policy of the Allergy Institute, P.C. that a minor should not be treated without the consent of a parent or legal guardian.
as the parent/legal guardian give permission to treat my minor child when I am not present. I understand this care/treatment may include but not limited to allergy shots, office visit, skin testing, and/or lab work.
This consent will expire on
's eighteenth birthday, unless I revoke this consent in writing.
I understand that by refusing to sign or if I revoke this consent, Allergy Institute, P.C. will refuse to treat my minor child unless I am present. This is in accordance with Iowa Code Chapter 599.
I fully understand and accept the terms of this consent.