Consent for Treatment for Minor With or Without Adult Present

Parent Guardian

give Dr. McMullen, Hillary Spears, FNP or Jakelyn Alfaro, FNP permission to treat my minor child,

(Patient name- please print)

Date of Birth:

without my presence or presence of an adult.

with an adult of whom I give permission.

Name:

Relation:

Name:

Relation:

Name:

Relation:

Name:

Relation:

Name:

Relation:

I understand that this letter can be revoked at any time. If there should be a medical emergency, I can be reached at:

DISCLAIMER: 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.

Parent/Guardian Signature:

Date:

Your information will be encrypted.

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