CONSENT FOR TREATMENT FOR A
MINOR
Patient
Name: ______________________________________________
Date
of Birth: ______________________________________________
I,
undersigned, parent/guardian of ______________________________, a minor, do
hereby authorize and direct Dr. Rajeev Agarwal and staff of Desert Ridge
Children’s Center to provide on going routine and emergency health care.
_________________________________________________________
Parent/Guardian
(Name and Signature) Date
_________________________________________________________
Witness
(Name and Signature) Date