• Designation Form

    This form allows you to designate another person(s) provide consent for treatment if you are unable to accompany your child to London Women's Care.
  • Parent or Legal Guardian Information

    Please provide your name and date of birth, as the parent or legal guardian of the child.
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  • Child (Patient) Information

    Please provide the name and date of birth of the minor patient.
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  • Designee Information

    Please provide the following information for the person(s) that you authorize to provide consent of treatment for your child. The person(s) listed must be at least 18 years of age or older. I understand that this designation may include medication and treatment, but does not include consent for vaccines.
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  • Authorization & Signature

    As the parent or legal guardian listed above, I affirm that I am unable to accompany my child to London Women's Care. Therefore, I give permission to the Designee(s) listed above to provide consent of treatment for my child, which may include medication and treatment, but does not include consent for vaccines.
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