Authorization To Accompany Child

There may come a time when parents/guardians cannot be available to bring their child/children to our office for care. During this time, while your child is in the care of someone else, we must have the information below in order to treat your child.

In presenting my child/children for diagnosis and treatment, and when accompanied by the below listed individual, I hereby voluntarily consent to the rendering of such care, when including medical treatment by authorized members of Dr. Schulman and his medical staff, as may in their professional judgement be necessary. I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on child's conditions.

I have read this form and I understand its contents.

We/I hereby give my consent to:

I authorize the designated individual to arrange for routine or emergency medical treatment, if necessary, to preserve the health of our/my child. I acknowledge that I am responsible for all charges in connection with the care and treatment rendered.

I understand that it is my responsibility to inform this office of any change in my child's medical status. I understand if I fail to complete this form, that Dr. Schulman will not treat my child, unless accompanied by anyone other than the registered parent/guardian as listed on the Patient Registration Form.