This is a permission form for adults (18yrs and older) other than the parents or legal guardians to bring the child(ren) to the office for medical care, and to
give consent for medical treatment.
The purpose of this form is to allow you, the parent, the option of naming other adults to bring your child(ren) to the office of Onyinye Okezie M.D. Inc.
for medical evaluations and treatment. You will be giving permission for these adults to discuss your child’s personal medical history with the staff
of Onyinye Okezie M.D. Inc. as needed and to make any medical decisions needed at the time of the appointment, not excluding any medical emergencies.
This authorization will be valid: