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Consent to Treat Minor

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Am unable to bring my child to the office for an examination and treatment, I offer my consent and authorization to the following individuals ( all of whom are over the age of 18) to receive medical care for my child. I also give Kidz & Family Medicine permission to share any information about my child’s appointment, insurance, test results, or medical care to the people mentioned below. I realize that this gives the preceding person(s) permission to agree to medical and surgical procedures and vaccines that are connected to the patient’s healthcare needs. This authorization will remain in effect until I notify Kidz & Family Medicine in writing of any changes
Complete Name
Relationship
Phone number

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