KAP Non Guardian Consent

Please correct the errors described below.

I am the parent or guardian of [Patient Listed Below] I have the legal right to consent for medical treatment for this child (patient).

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I authorize the following individual, who is a person over 18 years of age and whose relationship to the child is:

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to bring the child to his or her medical appointment, and to consent to medical care which is deemed necessary by the physicians and medical providers at KAP at the time of the appointment. I understand that this delegation includes receiving health information about the minor necessary to make immediately necessary health care decisions.

By signing this form, I attest that I have personally read this form (or had it explained to me) and fully understand and agree to its contents.

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