I {parentguardianName14} acknlodegement that i am authorizing consent for {parentguardianName16} to bring the above child(ren) to PHA for exam,treatment and any esscary medical care. {parentguardianName16} is aware that they will be responiible for payment at the time of service. I authorize the PHA to perform the treatment or necessary procedure for my child(ren) listed above.