Form - Child Consent | Dr. Okezie Pediatrics | Pediatric, Child Doctor

Child Consent Form

First Child's Full Name*
First Child's Date of Birth*
MM slash DD slash YYYY
Second Child's Full Name
Second Child's Date of Birth
MM slash DD slash YYYY
Third Child's Full Name
Third Child's Date of Birth
MM slash DD slash YYYY
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:
From*
MM slash DD slash YYYY
To*
MM slash DD slash YYYY
and must be renewed annually.
Parent's Full Name*
Adult's Full Name*
Relation to Child*
This form may be modified in writing at any time at the request of the parent. To remove an adult from this list parent must do so in the office.
Parent/Legal Guardian's Full Name*
Relation to Child(ren)*
Digital Signature*
- I Agree.
Parent Signing*