Consent To Treat Minors – Primary and Urgent Care

Child Name *

First

Last

Child's DOB *

Child's Date of Birth

Parent Name *

First

Last

Parent's DOB (copy) *

Parent's Date of Birth

Parent Email *

Parent Phone Number *

Parental Consent for Child to be seen in the absence of a parent and with another adult *

Yes, I provide consent
No, I do not provide consent

Name of Person Accompanying Child

First

Last

Date of Birth of Person Accompanying Child *

Date of Birth of Person Accompanying Child

I authorize Pediatrics & Urgent Care’ providers to provide medical care for my child. In the event that my child is brought to the clinic by anyone other than a legal guardian or me, I authorize that my child may be treated in my absence. I understand that I am responsible for settling any costs arising from this care provided in my absence. The following person(s) have my permission to authorize medical care for my child and sign any necessary waivers on my behalf *

Clear Signature

Signature