Parental Consent For Medical Treatment & Pharmacy Information Form printable pdf download

Parental Consent For Medical Treatment & Pharmacy Information Form

DOCTORS INLET PEDIATRICS & PRIMARY CARE, P.A.

d/b/a Avenues Pediatrics & Avenues Internal Medicine

430 College Drive, Suite 100-102-104

10175 Fortune Parkway, Suite 401

Middleburg, FL 32068-8531

Jacksonville, FL 32256-6746

PARENTAL CONSENT FOR MEDICAL TREATMENT & PHARMACY INFORMATION

WHO ARE THE LEGAL PARENTS/GUARDIANS OF THIS CHILD?

(If Guardian, legal documents need to be provided)

Name: ______________________________

Relationship: ______________________________

Name: ______________________________

Relationship: ______________________________

I, ________________________________, am the parent/legal guardian of the following named child:

____________________________________________ DOB ____________________

I hereby authorize any one of the following adult individuals to obtain medical treatment for any/all the

above named children, and to give/receive medical information, that is deemed necessary and appropriate

for treatment by a physician licensed in the state of Florida. This consent includes, but is not limited to,

medical and surgical intervention and elective, as well as emergency care.

__________________________________________ RELATIONSHIP ______________

I further agree to reimburse the health care provider for the cost of rendering these services.

This consent for treatment is good until withdrawn by parent/legal guardian.

______________________________________________ DATE ___________________

Signature of Parent/Legal Guardian

PHARMACY INFORMATION

Pharmacy Name: ________________________________ Phone #: __________________

Address: __________________________________________________________________

City: ______________________________________

Zip: ______________________

PLEASE NOTE THIS PHARMACY WILL BE USED FOR ALL PRESCRIPTIONS.

PLEASE NOTIFY US OF ANY CHANGES IMMEDIATELY.

OFFICE STAFF:

Driver’s License and Photo Identification checked and scanned into system __________

Initials

Address on Driver’s License matches information on form

__________

Initials

Parental Consent For Medical Treatment & Pharmacy Information Form