TEXAS REGIONAL ASTHMA AND ALLERGY CENTER, L.L.P.
I hereby authorize Texas Regional Asthma & Allergy Center, L.L. P. to provide medical care to the patient below without a legal guardian present. Medical care may include a physical examination, certain diagnostic tests, allergy injections, medications by prescriptions, oral or injection.
DISCLAIMER: By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
over the phone and was given a verbal consent to treat.
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