I, the Parent/Guardian of the above named patient, hereby request and authorize Pedi-Q Urgent Care and its personnel to deliver medical care to my child listed above as may be deemed necessary or advisable in the diagnosis and treatment of the minor child. This medical care may include but is not limited to: medical evaluation, physical exam, medication administration, injections, x-rays, lab work, procedures (laceration repair, burn care, incision and drainage), transportation to local emergency department, and ACLS (Advanced Cardiac Life Support).
I acknowledge that the adult presenting the child (referred to as the “Accompanying Adult”) is responsible for any copays, deductibles, past balances, or collections balances at registration at the time of service.
I acknowledge that I am financially responsible for the payment of any charges incurred at Pedi-Q Urgent Care for the above named patient.
I acknowledge that I have reviewed both the Office Policies and Procedures and HIPAA Omnibus Notice of Privacy Policies of Pedi-Q Urgent Care at www.pedi-q.com, and agree to the terms of these policies.
I hereby authorize Pedi-Q Urgent Care and its personnel to deliver medical treatment and services to my child, and I have read, understand, and give my consent as stipulated above. I understand that my signature below further means that I have read this Unaccompanied Minor Consent form, the Office Policies and Procedures, and HIPAA Omnibus Notice of Privacy Policies and/or have had it read to me and explained in the language that I can understand.
This form is valid from the date of signature until revoked in writing.