I, name am the parent or legal guardian (parent or legal guardians name PRINTED) of (child’s name coming for appointment) whose date of birth is ,
do hereby consent to any medical care and/or administration of immunizations determined by a provider to be necessary for the health and welfare of my child while under the care of (person bringing the child to appointment) .This authorization is effective form (start date of consent) to (end date of consent) .
This form must be brought with the child to the providers’ office when the child is taken for treatment. The child cannot be treated without this form if the parent or legal guardian is not with the child at the time of service.