• Emergency Medical Authorization

  • I,   *   * parent/guardian of   *   *   , date of birth being   Pick a Date*   , do hereby give permission to StarBright Applied Behavior Analyst PLLC, to secure and authorize such emergency medical care and/or treatment as above-named child might require while under the supervision of StarBright ABA. I further authorize StarBright ABA to administer emergency care/treatment as required, until medical assistance is available. I also agree to pay all costs and fees contingent on any emergency medical care and/or treatment for said child as secured or authorized under this consent.

  • NOTE: Every effort will be made to notify parents immediately in case of emergency.

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