ࡱ > } ~ O bjbj99 8 pSWipSWi* ` ( ( 8 ! . . . . . $ ! T . . F . . ( . H^ O R 0 ! " p " ( " ( d p ! " ( X : Consent to Treat Minor Children
Please print all information
I, ____________________________________________, am the parent/legal guardian of ____________________________ ____________, born on _____________________________. I consent to any medical treatment, including but not limited to, diagnosis, examination, and/or medical procedures that may be deemed necessary or advisable by any licensed physician or medical facility for the health and welfare of my child.
I understand that medical treatment may include medication, diagnostic tests, or other medical procedures, and I authorize such treatment as deemed necessary by the licensed medical professionals responsible for my childs care.
I further understand that unforeseen conditions or complications may arise during treatment, and I authorize the licensed medical profession or medical facility to take such measures as deemed necessary to protect the health and welfare of my child.
I certify that I have the legal authority to provide this consent and that all information is accurate to the best of my knowledge.
____________________________________________ ________________________________
Signature of Parent/Legal Guardian Date Signed
Parent/Legal Guardian name (printed): _____________________________________________
Parent address: ________________________________________________________________
Parent phone number: __________________________________________________________
Parent email address: ___________________________________________________________
Phone 260.665.4100 1 University Avenue, Angola, IN 46703-1764 www.trine.edu
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Illustrator
2008-07-16T08:32:48-04:00
2008-07-16T12:33:03Z
2008-07-16T08:32:48-04:00
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uuid:E3F7151AA454DD1190C492792D62E67D
uuid:E4F7151AA454DD1190C492792D62E67D
uuid:5D2A74DA92F5DC11B3F69D1DC1B0FE72
uuid:5C2A74DA92F5DC11B3F69D1DC1B0FE72
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