Consent to Treat a Minor

Please correct the errors described below.

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.

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.

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