Consent for Treatment - Convoy Office Forms

Parent Consent for Treatment of Minor

Nicodemus M. Watts, MD, DFAACAP
This is to authorize Nicodemus M. Watts, MD, DFAACAP, to evaluate and/or treat my child,
Child's Full Name *
I understand that the evaluation and/or treatment process may include counseling and/or medication, may involve other members of the family and the exchange of information with other professional agencies and individuals with a signed release of information form. I understand that I have a right to receive a copy of this authorization.
Signature of Parent/Legal Guardian *

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Printed Name *
Date *

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Date
Signature of Parent/Legal Guardian

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Printed Name
Signature of Patient *

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Printed Name *
Date *

Month Day Year
Date
Witness Signature

To be completed by your physician Clear
Printed Name
Date

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Date
Nicodemus M. Watts, MD, DFAACAP Diplomate, American Board of Psychiatry & Neurology Distinguished Fellow, American Academy of Child & Adolescent Psychiatry Child, Adolescent & Adult Psychiatry
3760 Convoy Street, Suite 113 San Diego, CA 92111-3743 Office: (858) 598-5207 Fax: (858) 598-5089
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Parent Consent for Treatment of Minor