Consent to be Seen

Consent to be Seen
Date

MonthDayYear
Date
In my absence, I hereby give authorization for the person(s) listed below to bring my child(ren) to Chisholm Trail Pediatrics and to consent for any and all recommended medical services.
Patient Name
Date of Birth

MonthDayYear
Date
Patient Name
Date of Birth

MonthDayYear
Date
Patient Name
Date of Birth

MonthDayYear
Date
Authorized persons (must be 21 years of age or older)
Relationship to patient
Authorized persons (must be 21 years of age or older)
Relationship to patient
Authorized persons (must be 21 years of age or older)
Relationship to patient
Authorized persons (must be 21 years of age or older)
Relationship to patient
**PLEASE NOTE***

All minor children (anyone under the age of 18) must be accompanied by a parent, legal guardian, or authorized adult listed above over the age of 21.

This authorization will remain in effect until changes are made by the parent/legal guardian as signed below.
Parent/Legal Guardian Signature

Clear
Printed Name
Should be Empty: