Consent for Non Guardian

Patient Name(Required)

I Confirm

I am the parent or guardian of the above named patient. I have the legal right to consent for medical treatment for this child (patient).

I Authorize

I authorize the following indivudal(s), who is a person(s) over 18 years of age and whose relationship to the child is listed below to bring the child to his or her medical appointment and to consent to medical care by the clinician(s) of Center for Emotional Health. I understand that this delegation includes receiving health information about the minor, necessary to make decision for the patient medical/mental health care.
Name
Name
Name

Final Authorization

I understand by giving permission to the above named individuals to bring my child to the appointment and make medical decisions for my child that I am authorizing changes to be made to the medication regimen and dosages as I currently know it and I will not be involved in communication related to an appointment that the named individual attended on my behalf. I understand that to discuss further changes after this appointment I will be required to schedule an additional appointment.
This consent is valid for one year from the date on this form unless revoked sooner by the parent or legal guardian
Name
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