RTC Pediatrics Authorization Form for Appointment and Treatment Logo
  • RTC Pediatrics Authorization Form for Appointment and Treatment

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  • Authorized Person(s):

  • Effective Date of Authorization:

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  • Parent/Guardian Acknowledgement:

    I, the undersigned parent/guardian, that by signing this form, I am authorizing the designated person(s) above to make medical decisions regarding my child's care, if necessary, during their appointments at RTC Pediatrics.
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  • Should be Empty: