4-CONSENT TO TX & RX POLICY FORM

Consent to Treat and Prescription Policy
I hereby give permission for the following people to obtain medical care for my child named below, and to have access to my child's medical records (this could be adult relatives/babysitters/nanny etc.):
(Patient Name / Date of Birth)*
(Name / Relationship)*
(Name / Relationship)*
(Name / Relationship)*
(Name / Realtionship)*
Nxt Step Pediatrics is committed to providing you with the best care possible. This goal is best achieved if everyone is aware of ourprescription request policy. In order to fill prescriptions in a timely manner, we need your assistance with the following:

1. Typically, a child must be seen before a medication can be prescribed for the first time Exceptions are at the physician's discretion only.

2. Please allow 7 DAYS for a prescription to be filled after it is requested. With this in mind, please allow adequate time for the provider to complete your request BEFORE your child's prescription

IMPORTANT: If your child is prescribed a medication and appears to be having a reaction to it, please call our office immediately. It is imperative that our providers are aware of any reactions that need to be documented and followed up on.
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Consent to Treat and Prescription Policy