PARENTAL CONSENT FOR TREATMENT OF CHILD

(Please be certain to sign in each of the three places and fill-in the insurance information. This is NOT 

optional.)

Parental consent for the treatment of minors in the case of illness or accident. Parental permission must

be obtained before medical treatment can be rendered to persons under 18 years of age. The following consent

from should be signed by the parent or guardian so that indicated care might be given with no unnecessary

delay. No major procedures will be performed, except in extreme emergency, without parent being notified and

fully informed. In the event that a parent does not want treatment rendered under any circumstance, the parent

should cross out the work “give: on the form below and insert the word “refuse”. If the form is not signed, it will

be interpreted as a refusal of permission.

I give permission to the physician(s) at any physician’s office, hospital, or clinic to carry out such emergency diagnostic and therapeutic procedures as may be necessary for my son/daughter, and in the physician’s

absence for the nurse on duty to render emergency care in line with standing order.

Clicking "Yes" below, you are agreeing to above information