Consent from Parents or Guardians for Authorized Persons:
As the parent or guardian of for the below listed person(s) to bring my child in for treatment and/or care.
PLEASE SELECT ONE OF THE FOLLOWING CHOICES:
I am granting full permissions, meaning the below-listed person(s) will be allowed to agree to treatments/vaccines, and know all health history pertaining to my child.
I am granting permissions, meaning the below-listed person(s) is only allowed to bring my child in, and will have access to all health history, but not allowed to agree to treatments without my direct consent.
I am granting limited permissions, meaning the below-listed person(s) is allowed to bring my child into the office, but is not allowed access to any medical information or treatment of my child. I will be informed of the visit results, and I will be notified prior to any treatment for my child.