• Parent/Guardian Consent for Treatment

  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Birth:
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.

  • Authorized Person(s):

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Effective Date of Authorization:

  • Start Date:
     - -
    2 digit month, 2 digit day, 4 digit year
  • End Date (if applicable):
     - -
    2 digit month, 2 digit day, 4 digit year

  • 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.
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year

  • Form Disclosure

    By submitting this form, you agree that [Practice Name] may use the information you provide to respond to your request and, where applicable, to contact you about your child's care. We do not sell your information. View our full Privacy Policy at https://www.rtcpeds.com/privacy-policy.

  • Should be Empty: