I, the undersigned, am the parent or legal guardian of the minor listed above. I hereby authorize Anchorage Medical Services (AMS Urgent Care) and its medical providers to evaluate and provide medical care, including diagnosis, treatment, and procedures, deemed medically necessary for the above-named minor. I understand that this consent applies when I am not physically present at the time care is provided. I give permission for my child to receive medical care, including but not limited to: Evaluation and treatment of illness or minor injuries Physical exams Diagnostic testing (e.g., labs, imaging) Administration of over-the-counter or prescription medications as deemed necessary by the provider Optional: Additional Individuals Authorized to Accompany Minor The following individuals may accompany my child and are authorized to make medical decisions in my absence:

Optional: Additional Individuals Authorized to Accompany Minor

The following individual may accompany my child and are authoized to make medical decisions in my absence