• Authorization for Medical Treatment

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

  • u   u    u

  • 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

  • Patient(s) Names:

  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  •  -  -
    Pick a Date
  • u   u    u

  • Clear
  •    
  • Should be Empty: