I hereby consent to examinations, treatments, and procedures (including emergency treatments) which may be deemed necessary by our physicians, their associates or staff.

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I authorize the staff of RDV Sportsplex Pediatrics to contact the following individuals by phone to deliver test results, gather additional information, or authorize care in the following order:

(Note: Both parents/guardians are usually listed first, followed by any other individuals if any.)

In my absence, I authorize the following individuals to accompany my child to the office of RDV Sportsplex Pediatrics, and seek medical care and authorize treatment.

u u u

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