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Patient Name
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DOB
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I (We) the parent (s) or legal guardian (s) authorize the individual (s) named below to act in my (our) behalf with the full authority to grant permission for any medical treatment or surgical procedure that is in the best interest of the above named child in the opinion of the Kids First Pediatrics of GA physicians. This also authorizes physicians to discuss confidential health information concerning the patient with the individuals who are authorized to bring the patient into the office for medical treatment. I understand that the physician may request to contact the parent/ guardian prior to providing medical treatment even though this consent is presented. I understand that as parent(s) or legal guardian(s) that I am financially responsible for all care received as a result of this consent. ADULTS THAT MAY CONSENT FOR MEDICAL TREATMENT IN MY (OUR) ABSENCE: (Authorized individuals should also be listed in Privacy Practices)
Name
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Phone #
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Relationship to Patient
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Name
Phone #
Relationship to Patient
Name
Phone #
Relationship to Patient
Name
Phone #
Relationship to Patient
Name
Phone #
Relationship to Patient
This consent form will be in effect for 12 months from signing or less time if specified. AUTHORIZED BY: (Both parents signature preferred, but not required) By signing below, I certify that I am the legal parent or guardian of the child identified above and that I am acting within my authority in signing this Pediatric Consent form.
Mother (Printed):
Signature
clear
Date
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Father (Printed):
Signature
clear
Date
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Legal Guardian (if not father or mother) (printed)
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Signature
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clear
Date
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Please Note:
Any information submitted using this form is transmitted securely and held in the strictest of confidence, protecting your privacy.
* = Input is required