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Parental Consent for Medical Treatment
When you go away, make sure your children are protected. Accidents or sudden illness involving your children can occur at any time, any place. Unfortunately parents or guardians are not always immediately available to give proper consent and valuable medical information.
Southdale Pediatrics would like to help you prevent this from happening. This Parental Consent for Medical Treatment form gives a caregiver permission to consent to treatment for your child.
This form must be presented when someone other than a parent or legal guardian will be bringing your child to the clinic.
- Please be thorough and complete all of the information.
- You must complete a separate form for each child.
- Remember to send along a form any time your child is being brought to our clinic by someone other than a parent or guardian.
Please click on the link to the form to open it and then click on the picture of the printer which appears just above the opened form to print a copy to fill out.
Parental Consent For Medical Treatment
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