Parent/Guardian Consent for Treatment
Patient Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Patient Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Patient Name:
First Name
Last Name
Date of Birth:
-
Month
-
Day
Year
Date
Parent/Guardian Name:
First Name
Last Name
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
Email:
example@example.com
Relationship to Patient:
Authorized Person(s):
Name:
Relationship to Patient:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Name:
Relationship to Patient:
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please list any limitations to this authorization (e.g., types of treatment, specific dates, etc.):
Effective Date of Authorization:
Start Date:
-
Month
-
Day
Year
Date
End Date (if applicable):
-
Month
-
Day
Year
Date
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.
Signature
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: