MEDICAL AUTHORIZATION AND CONSENT FORM


Patient’s Name:
File No.:
DOB:
Mobile Number:
Doctor Name:
Visit Date:

In Presenting my son/daughter for diagnosis and treatment. I, being the parent and / or legal guardian of hereinafter, my child do hereby authorize the Clinic to seek and obtain medical care including diagnostic procedures, medical treatment such as administration of medicine, nebulizer, ear syringe wound treatment and vaccination by authorized members of clinic staff to their designees, as may in their professional judgement be necessary for my child in the event that he/she need (s) medical care.

My child has the following allergies:

We/I acknowledge that we are (I am) responsible for all reasonable charges in the connection with the care and treatment rendered to my child under this Authorization.

Signature of Parent (or Legal Guardian):

Witness Name(MEDICAL STAFF) & Signature
Date

Doctor Name :
Signature