I, the legal parent/guardian of the above named person, 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 am also aware that I am still financially responsible for payment of the patient portion at the time of service, as well as another other charges incurred in office.
I acknowledge that I have reviewed both the Office Policies and Produres 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 furhter 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.