Pediatric Medical Care Informed Consent

Patient Information

Child's Full Name: ________________________________ Date of Birth: //____ Parent/Legal Guardian Name: ________________________

Consent for Treatment

I, the undersigned parent/legal guardian of the above-named minor patient, hereby authorize [PRACTICE NAME] and its healthcare providers to provide medical care to my child, including but not limited to:

• Physical examinations
• Diagnostic procedures
• Immunizations
• Laboratory tests
• Medical treatments
• Emergency care when deemed necessary

Authorization for Medical Decision-Making

I understand and acknowledge that:

1. The practice will explain:

   • The nature of my child's medical condition
   • Proposed treatment options
   • Potential risks and benefits
   • Alternative treatments

2. I have the right to:

   • Ask questions about my child's care
   • Refuse treatment
   • Seek a second opinion

Information Release Authorization

I authorize the release of medical information necessary to:

• Process insurance claims
• Coordinate care with other healthcare providers
• Comply with legal requirements

Financial Responsibility

I understand that:

• I am financially responsible for all charges
• Insurance coverage verification is my responsibility
• Co-payments are due at time of service

Emergency Contact Authorization

In case of emergency, if I cannot be reached, I authorize the practice to:

1. Provide emergency medical care
2. Contact my designated emergency contacts
3. Arrange emergency transport if necessary

Signature of Parent/Guardian

Date

Witness Signature

Valid for one year from date of signature unless revoked in writing.