Consent to Consent to Treatment of a Minor Child
In presenting my son/daughter for diagnosis and treatment, I
Mother
Father
Legal Guardian
Other
Name of person providing consent
Name
Provide consent for my
Son
Daughter
Other
Patients Name
Age of Child
hereby voluntarily consent to the rendering of such care, including all aspects of occupational therapy, such as modalities, ice and electrical stimulation, ultrasound, exercises, etc., by authorized members of Hands On Care and staff, as may in their professional judgment be necessary.
I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child’s condition. I have read this form and certify that I understand its contents. We/I hereby give our (my) consent to Hands on Care's Staff who will be caring for our (my) child
Initial
We/I acknowledge that we are (I am) responsible for all reasonable charges in connection with care and treatment rendered during this period.
Policy Holder's First Name
Last Name
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of Primary Caregiver
-
Area Code
Phone Number
Date of Birth of Primary Card Holder
-
Month
-
Day
Year
Date
Email Address of primary caretaker
*
Child’s allergies, if any:
Signature of Mother, Father or Legal Guardian
Submit
Should be Empty: