Consent to Treatment of a Minor

Patient Name: Type a label DOB: Date

I, the undersigned, attest that I am the custodial parent or legal guardian of the above-referenced Minor ("the minor"), and hereby authorize Clinical Pediatric Associates of North Texas to administer treatment as it so deems necessary to the minor. In no event shall my signature to any other such document have any effect on this consent form.

Name of Parent/Legal Guardian (1): Full Name DOB: Date Relationship to Patient: Parent- Mother/Father Legal Guardian Date of legal guardianship Driver's License #: ID Number Phone Number: Phone Number Address: Street Address City State Zip

Name of Parent/Legal Guardian (2): Full Name DOB: Date Relationship to Patient: Parent- Mother/Father Legal Guardian Date of legal guardianship Driver's License #: ID Number Phone Number: Phone Number Address: Street Address City State Zip

The listed person(s) below has permission to bring the minor & consent to any X-Ray, examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice or any physician or surgeon licensed to practice in the state of Texas, when the need for such treatment is immediate, and when efforts to contact me (us) are unsuccessful:

Name: Full Name Relationship to Minor: Relationship Drivers License: DL or ID Address: Street Address City State Zip

Name of Company: Company Name Company Address: Street Address City State Zip Phone #: Phone Number Policy #: Policy

I would like to request with the Physician/Provider approval that my son/daughter to be seen on follow-up or subsequent visits without parent/guardian attending since he/she is 16 years of age or older and has my permission. YES NO

Signature: Signature Date: Date Expiration Date: Date

Witness Name: Full Name Witness Signature: Signature Date: Date

Consent to Treatment of a Minor

Insurance Information