Synergiquehealing.com - Non Parent Consent Form

Consent for Non-Parent to Bring Minor Child to Appointment and Release of Medical Records
Name of Patient

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I am the parent or guardian of First Name* Last Name* (legal name of patient) I have the leal right to consent for medical treatment for this child (patient).

I authorize the following individual who is a person of 18 years of age or older and whose relationship to the child is:
Full Legal Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Relationship to Patient
This person above is authorized to bring the child to his or her appointment, to consent to medical treatment which is deemed necessary by the physicians and medical providers at Synergique Healing at the time of appointment. I understand that this delegation includes authorizing the individual above to give and receive medical information/records about the minor necessary to make immediate health care decisions.

This consent is valid until revoked in writing by me, the parent or legal guardian.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Printed Name

First NameLast Name
Contact information for parent/guardian
Please enter a valid phone number.Format: (000) 000-0000.

8703 Meadowcroft Dr. Houston, TX 77063	P# 713-840-7956 Fax:281-972-8349
Email: admin@synergiquehealing.com	https://synergiquehealing.com/

Consent for Non-Parent to Bring Minor Child to Appointment and Release of Medical Records