Consent for Treatment

Parent Consent for Treatment of Minor

Nicodemus M. Watts, MD, DFAACAP
This is to authorize Nicodemus M. Watts, M.D., 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:*

MonthDayYear
Signature of Parent/Legal Guardian

Clear
Printed Name
Signature of Patient:*

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Printed Name:*
Date:*

MonthDayYear
Witness Signature:

Clear
To be completed by your physician
Printed Name:
Date:

MonthDayYear
Nicodemus M. Watts, MD, DFAACAP Diplomate, American Board of Psychiatry & Neurology Distinguished Fellow, American Academy of Child & Adolescent Psychiatry Child, Adolescent & Adult Psychiatry
12625 High Bluff Drive, Suite 111 San Diego, CA 92130-2053 Office: (858) 598-5207 Fax: (858) 598-5089
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Parent Consent for Treatment of Minor