Orange Pediatrics Page 4
ADVERTISEMENT
1
2
3
4
5
6
7ORANGE PEDIATRICS
251 Maitland Ave Ste 104 Altamonte Springs FL 32701
Ph: 407-557-2165
Fax: 407-369-4612
AUTHORIZATION FOR MEDICAL TREATMENT
Child’s Name: ___________________________
Child’s date of birth:_______________________
Your name:______________________________
Your relationship to child:
Biological Mom
Biological Dad
Foster Parent
Legal Guardian
Other (Please Specify)
1. I, ______________________________________________________hereby, give consent to
examinations, treatments, and procedures, including emergency treatments which may be
deemed necessary by Dr. Devyani Belsare and her Associates at Orange Pediatrics.
2. In the event of an EMERGENCY, I authorize the staff of Orange Pediatrics to contact the
following persons for information and authorization of medical care.
1st
Name
Relationship
Phone
2nd
Name
Relationship
Phone
3rd
Name
Relationship
Phone
In the event of such an emergency, I can be reached at:
Home Phone #: ______________________Work/Other: Phone #: ______________________
3. In my ABSENCE, I authorize the following individuals to accompany my child to the office
of Orange Pediatrics or any medical facility serviced by their staff, and to seek medical care and
to authorize treatment.
Name
Relationship
Phone
Name
Relationship
Phone
Name
Relationship
Phone
Parent/Guardian signature__________________ Today’s Date: ____________________
Pg 4 of 7
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Medical