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Consent Form – Treatment of a Minor
Authorization for Agent to Consent to Treatment of A Minor
Consent Form – Treatment of a Minor
admin-pioneer
2020-05-21T16:18:04-04:00
Consent Form - Treatment of a Minor
Pioneer Location
*
Columbia Woods Medical Group
Diamond Family Practice
Fairlawn Family Practice
Family Practice Associates
Family Practice Center of Wadsworth
Great Trail Family Practice
Hearthstone Family Practice
Internal Medicine of Green
Internal Medicine West
Louisville Medical Center
North Canton Family Physicians
Northampton Primary Care
Northeast Family Health Care
Ohio Family Practice
Pioneer Foot & Ankle Care
South Main Street Medical Center
Springfield Primary Care
Springside Internal Medicine
Stow Internists
Name of Child/Minor
*
I, the undersigned, parent/guardian and agent of the above child/minor, do hereby authorize to consent to any xray, medical examination, anesthetic, medical or surgical treatment and/or hospital care which is deemed advisable by and is to be rendered under, the general or special supervision of any Pioneer Physicians Network physician.
This authorization shall remain in effect from
*
Through
*
unless revoked in writing.
Name
*
Parent/Guardian - Please Print
Relationship
*
Date
*
Signature
*
Clear
Witness
Clear
Submit
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