Parent/Guardian Consent for Treatment

Parent/Guardian Consent for Treatment
Patient Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Patient Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Patient Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Parent/Guardian Name:

First NameLast 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:

MonthDayYear
Date
End Date (if applicable):

MonthDayYear
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

MonthDayYear
Date
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:

Authorized Person(s):