Consent to Treat Authorization

Johns Creek Pediatrics

Please correct the errors described below.

I hereby give authorization to the following named individuals to accompany my child/children for treatment at Johns Creek Pediatrics, PC:

Add New Individual

This includes, but is not limited to, medical evaluation, treatment and administering of immunizations.

Add New Child

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

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