who is a minor. If I am divorced from the minor’s other parent, I have sole or joint legal custody of such minor.
I hereby give consent to Children’s Burn Foundation to provide all emergency dental or medical care prescribed by a duly licensed physician (M.D Osteopath (D.O or Dentist (D.D.S for my child. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent. I hereby authorize Children’s Burn Foundation staff or their authorized representative, as agent(s) for the undersigned to consent to any x-ray examination, anesthetic, medical, dental or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any licensed physician and the medical staff of a licensed hospital, whether such examination, diagnosis or treatment is rendered at the office of said physician or at such hospital.