Consent to Treatment With Accompanied Person - English Form

Please correct the errors described below.

from one of the providers at Partners In Health Pediatrics.

This consent is valid for the following dates:

I understand that parent/ guardian is required at, both, the first well exam and first sick visit.

For the reason of insufficient information given by the authorized person for the visit, provider may ask to reschedule the visit with parent / guardian.

I understand that I may revoke this authorization at any time except to the extent that treatment has already been taken by relying on it. I understand that this consent to treat authorizes this individual full access to patient's medical records

Please provide the information about the Picture ID that the individual, you are consenting above, will use as Identification:

Add New ID

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.

Your information will be encrypted.