Patient Information Consent Form

Patient Name Printed *

First

Last

Signing as parent or guardian?

Yes

This is to certify that I, as parent/guardian with legal responsibility for this patient, have read and understand the above consents, assignment of benefits, release of information, and late cancel/no show policy above, and I agree to his/her consent. I further understand that I assume liability for all aforementioned policies and procedures of the minor patient, as well as all penalties and fees outlined above.

Parent/Legal Guardian Name Printed

Relationship to Patient

Phone Number

Email