Consent to Treat Minors - Penn Medicine Becker ENT & Allergy

I/We,(Required)

Acting as the (check one)(Required)

Parent(s)

Legal guardian(s)

Of(Required)

[child's name]

hereby authorize Penn Medicine Becker ENT & Allergy [Caregiver] to seek, obtain, and

Provide consent for: (Check all that apply)(Required)

Routine medical care and treatment

Emergency medical care and treatment

Surgery

Hospitalization

Blood transfusions

Administration of medication

Other

Other(Required)

For(Required)

[child's name]

as determined necessary by a licensed medical or healthcare professional. This authorization is valid for the duration that my/our child is under the supervision of Penn Medicine Becker ENT & Allergy [Caregiver]

My/our child’s: (Please Check one)(Required)

And is effective(Required)

Until(Required)

Select a date

Revoked by me/us

Date(Required)

Child’s Information

Child’s Full Name(Required)

Address(Required)

Date of Birth(Required)

Age(Required)

Sex(Required)

Female

Male

Parent/Guardian’s Information

Parent/Guardian’s Name(Required)

Address(Required)

Phone Number (H)(Required)

Phone Number (C)(Required)

Phone Number (W)(Required)

Email(Required)

Parent/Guardian’s Information

Parent/Guardian’s Name(Required)

Address(Required)

Phone Number (H)(Required)

Phone Number (C)(Required)

Phone Number (W)(Required)

Email(Required)

Signature(Required)