Consent For Care


[PDF]Consent For Care - Rackcdn.comhttps://661e6855a6e58ebf9beb-4f5f148c1bb89ac271310458de510db1.ssl.cf2.rackcd...

4 downloads 215 Views 188KB Size

CENTENNIAL PEDIATRICS Chad D. Guetersloh, MD ∙ Christopher “Kit” Newton, MD, PhD ∙ Richard C. Nail, MD ∙ Susan Weiser Crow, MD ∙ Laura McClendon, MD Erin Bridgewater, MD ∙ Leslie Katz Lestz, MD ∙ Chad R. Smith, MD Deborah Arnold Smith, CPNP ∙ Thomas Atkins, CPNP 5560 Independence Parkway ∙ Frisco, Texas 75035 2701 Little Elm Parkway, Suite 115 ∙ Little Elm, Texas 75068 214.389.8801 phone 214.389.8802 fax

CONSENT FOR CARE FORM

I, ____________________, give permission for _____________________ to bring my (Parent’s Name) (Caretaker’s Name) child, ____________________________, for his/her appointment today. (Child’s Name) Please give them any instructions and/or prescription that may be needed.

In case of emergency, I can be reached at ____________________. (Contact Number)

Parent Signature: __________________________________ Date: ___________________________