DAVZ02 Consent to Treat Form

Consent to Treat – Non-Parent/Guardian to Accompany Patient

Davidson Family Medicine

This authorization gives below named person(s) permission to bring your child in, speak to the doctor, authorize the child for treatment, medications, certain procedures and to make general health decisions.

I, the parent/guardian of the below named child, give the person(s) listed below permission to bring my child to Davidson Family Medicine and to discuss and share medical information about my child. I further authorize them to see all necessary medical records and make health care decisions of a routine nature as determined at the sole discretion of the provider.

I also give them authority to make more serious or urgent health care decisions in the event I cannot be reached or where it is of an emergency nature where there is not sufficient time to seek out my specific consent.

Child's Name*

First NameMiddle NameLast Name

Date of Birth*

Date

Person(s) allowed to bring my child in for treatment

	Name of Person	Relationship	Phone Number
1.
2.
3.
4.

Name of Parent/Guardian*

First NameLast Name

Contact number where parent/guardian can be reached*

Please enter a valid phone number.

Digital Signature Authorization:*

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Signature of Parent/Guardian*

Date