Pediatric Treatment Agreement and Consent Form

Patient Information

Patient Name: _________________________ Date of Birth: _________________ Parent/Legal Guardian: _________________ Relationship: _________________

Agreement Terms

1. Consent for Treatment

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

• Physical examinations
• Diagnostic procedures
• Immunizations
• Laboratory tests
• Prescription medications
• Emergency care when deemed necessary

2. Financial Responsibility

• I understand that I am financially responsible for all charges
• I agree to pay copayments at the time of service
• I will promptly update insurance information when changes occur

3. Communication and Privacy

• I consent to receive communications regarding my child's healthcare via:
  • Phone calls
  • Text messages
  • Email
  • Patient portal
• I acknowledge receipt of the Notice of Privacy Practices

4. After-Hours Care

I understand that:

• After-hours care is available through the on-call service
• Emergency situations should be directed to 911 or nearest ER
• Routine matters should be addressed during regular office hours

5. Appointment Policy

• 24-hour notice is required for cancellations
• Repeated no-shows may result in discharge from practice
• Late arrivals may need to be rescheduled

Signatures

Parent/Guardian Signature: _________________ Date: _________________

Provider Signature: _______________________ Date: _________________

Witness: ________________________________ Date: _________________