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Consent to Treat Minors

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

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Routine medical care and treatment

Emergency medical care and treatment

Surgery

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Administration of medication

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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)

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MM slash DD slash YYYY

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Revoked by me/us

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Parent/Guardian’s Information

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Parent/Guardian’s Information

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Phone Number (C)(Required)

Phone Number (W)(Required)

Email(Required)

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Philadelphia, PA (South St)

215-671-6330

Philadelphia, PA (Walnut St)

Voorhees, NJ (Haddonfield-Berlind Rd)

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Freehold, NJ: (732) 375-9550
Hillsborough, NJ: (908) 271-2102
Lawrenceville, NJ: (609) 303-5163
Monroe, NJ: (609) 831-0779
Mt. Laurel, NJ: (856) 724-4031
Mullica Hill, NJ: (856) 478-3111
Philadelphia, PA: (215) 671-6330
Philadelphia, PA: (215) 929-8301
Plainsboro, NJ: (609) 681-6939
Princeton, NJ: (609) 759-8500
Princeton, NJ: (609) 430-9200
Robbinsville, NJ: (609) 436-5740
Sewell, NJ: (856) 589-6673
Voorhees, NJ: (856) 772-1617
Voorhees, NJ: (856) 565-2900
Yardley, PA: (267) 399-4004
Woodbury, NJ: (856) 845-8300