CONSENT FOR TREATMENT OF A MINOR CHILD

It is the policy of Valencia Pediatric Associates, that any new patient under the age of 18 must be seen in the presence of their parent or legal guardian for their first visit. An established patient [a patient known to the practice and seen within the past 12 months] may be brought in by an adult if written permission is given by the parent or legal guardian and that person shows valid photo ID. By filling out the form below you are giving consent for the adult(s) listed to bring your child in for their Valencia Pediatric Associates appointment(s) in your absence. We must be able to reach you by phone to discuss treatment during that appointment.

For

DOB:

Hereby voluntarily consent to the following person to bring my child to appointments at

Valencia Pediatric Associates:

Add Name

I can be reached at:

Telephone Number

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.

Date:

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