WESTERN WAKE WELLNESS

WESTERN WAKE WELLNESS

MINOR CONSENT TO TREAT
Parental Authorizaion pto treat Minor Child when not accoompanies by Parent or Guardian. This authorization is for patients under 18 years of age.
We must have permission from a child's parents or guardian before providing medical servies when the child is accompanied by someone other than the parent or Legal guardian or presents by him or herself. If you feel there may be an occasion where your child will be brought by a relative, sitter, etc, please complete the following information for us to include with your childs records.
Patient Name*
Patient Date of Birth

MonthDayYear
Date
The following person(s) have my permission to authorize medical care for my child and sign any necessary waivers/forms on my behalf.*
Signature of Parent/Guardian:

Clear
Printed Name of Parent/Guardian:
Relationship to Patient:
Date:

MonthDayYear
Date
Should be Empty: