CONSENT FOR CHILD’S MEDICAL/EMERGENCY TREATMENT AND MEDICAL INFORMATION Name: ___________________________________________ Mother Father Legal Guardian for child 1: ___________________________________ son daughter DOB: _____________ child 2: ___________________________________ son daughter DOB: _____________ child 3: ___________________________________ son daughter DOB: _____________ child 4: ___________________________________ son daughter DOB: _____________ In presenting my son/daughter for diagnosis and treatment, hereby voluntarily consent to the rendering of such care, including diagnostic procedures, by authorized staff of RUB PEDIATRICS MD PA or their designees, as may in their professional judgment be necessary in my absence. I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child’s condition. I have read this form and certify that I understand its contents. I/We hereby give my (our) consent to: 1. ___________________________________________________ (Name of Person/Agency) 2. ___________________________________________________ (Name of Person/Agency) 3. ___________________________________________________ (Name of Person/Agency) who may bring my child to RUB PEDIATRICS MD PA for medical attention as described above for my child/children aforementioned. I/We acknowledge that I/We are responsible for all reasonable charges in connection with care and treatment rendered during this period. Any co-payments and/or deductibles will still need to be paid by the person bringing the child to the office at time of visit. In case of emergency, I can be reached at: ( ) _____ - _________ Signature: ___________________________________ Driver’s Lic #: ____________________________ Date: ________________________ One or all of my children have the following allergies: (if none, write name of child and state “none” in the allergies section) Name of Child: Allergies: Name of Child: Allergies: Name of Child: Allergies: Name of Child: Allergies:

CONSENT FOR CHILD

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Informed consent regarding who is permitted to bring the child to the office and make necessary decisions in the absence of the parent or legal guardian. You should put grandparent's names, nanny names, or any other person permitted to bring the child to the office. If this form is not filled out, ONLY the legal mother, father or guardian will be permitted to bring the child to the office. NO EXCEPTIONS!

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CONSENT FOR CHILD’S MEDICAL/EMERGENCY TREATMENT AND MEDICAL INFORMATION

Name: ___________________________________________ Mother Father Legal Guardian for child 1: ___________________________________ son daughter DOB: _____________ child 2: ___________________________________ son daughter DOB: _____________ child 3: ___________________________________ son daughter DOB: _____________ child 4: ___________________________________ son daughter DOB: _____________ In presenting my son/daughter for diagnosis and treatment, hereby voluntarily consent to the rendering of such care, including diagnostic procedures, by authorized staff of RUB PEDIATRICS MD PA or their designees, as may in their professional judgment be necessary in my absence. I hereby acknowledge that no guarantees have been made to me as to the effect of such examinations or treatment on my child’s condition. I have read this form and certify that I understand its contents. I/We hereby give my (our) consent to:

1. ___________________________________________________ (Name of Person/Agency)

2. ___________________________________________________ (Name of Person/Agency)

3. ___________________________________________________ (Name of Person/Agency)

who may bring my child to RUB PEDIATRICS MD PA for medical attention as described above for my child/children aforementioned. I/We acknowledge that I/We are responsible for all reasonable charges in connection with care and treatment rendered during this period. Any co-payments and/or deductibles will still need to be paid by the person bringing the child to the office at time of visit. In case of emergency, I can be reached at: ( ) _____ - _________ Signature: ___________________________________ Driver’s Lic #: ____________________________ Date: ________________________ One or all of my children have the following allergies: (if none, write name of child and state “none” in the allergies section) Name of Child: Allergies: Name of Child: Allergies: Name of Child: Allergies: Name of Child: Allergies: