Medical Consent Form - Greater Knoxville Ear, Nose & Throat printable pdf download

Medical Consent Form - Greater Knoxville Ear, Nose & Throat

UT Medical Center • 1932 Alcoa Highway, Suite 160, Knoxville, TN 37920

Tennova North • 7557A Dannaher Drive, Suite 220, Powell, TN 37849

Sevierville • 1130 Middle Creek Road, Suites 120 & 130, Sevierville, TN 37862

West 220 Fort Sanders West Blvd., Suite 101, MOB II, Knoxville, TN 37922

Contact • Voice (865) 521-8050 • Fax (865) 637-6617 •

MEDICAL CONSENT FORM

Only complete this form if patient is under the age of 18.

Patient Name: _______________________________

Are you the legal guardian for this patient? 1YES

1NO

I hereby give my consent for the following individuals to bring my child/children

to:

Greater Knoxville Ear, Nose and Throat Associates, P.C.

For treatment of illnesses or injuries in my absence. This agreement will remain in

effect until I authorize cancellation by having this consent form removed from the

chart.

Signed: __________________________________

Parent or Legal Guardian

Witness: _________________________________

Below are the names, relationships and telephone contact numbers whom may

accompany my child/children to Greater Knoxville Ear, Nose and Throat

Associates, P.C.

PERSON(S) AUTHORIZED

RELATIONSHIP

PHONE NUMBER

__________________________________________________________________

_____________________________________________________________________________

__________________________________________________________________

DATE: ____________________

Medical Consent Form - Greater Knoxville Ear, Nose & Throat