4-CONSENT-TO-TREAT

CONSENT TO TREAT
I hereby give permission for the following people to obtain medical care information for my child, and to have access to my child's medical records. (This could be parents (Mom/Dad), Adult relatives, Babysitters, Nanny, etc).
Patient's Name*
Date of Birth*

MonthDayYear
Name 1*
(The name of the person currently filling out this form)
Relationship 1*
(Your relationship to the patient)
Name 2*
(Parent/Relative/Trusted Adult)
Relationship 2*
(Their relationship to the patient)
Name 3
(Parent/Relative/Trusted Adult)
Relationship 3
(Their relationship to the patient)
Name 4
(Parent/Relative/Trusted Adult)
Relationship 4
(Their relationship to the patient)
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

CONSENT TO TREAT