CONSENT TO TREAT MINOR

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.

Patient's Name:

DOB:

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.

Parent/Legal Guardian's Name(print):

Parent/Legal Guardian's Signature:

Withness:

Date:

VERBAL CONSENT TO TREAT MINOR

spoke with

Legal Guardian for

over the phone and was given a verbal consent to treat.

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.

Signature

Date:

Your information will be encrypted.