Child's Name *

First Name

Last Name

Parent/Guardian's Name *

First Name

Last Name

Phone *

(###)

###

####

By checking the box you certify agreement and understanding of the following Consent to Treatment: *

I voluntarily request the indicated pediatrician to perform reasonable and necessary medical examination, testing, and treatment on my child for the condition which has brought me to seek care. I understand I have the right at any time to discontinue services. I understand I have the right to discuss the treatment plan with the doctor, including the purpose, potential risks, and benefits of any test, treatment, or recommended course of action.

I agree

I do NOT agree and understand I will be unable to redeem by Golden Ticket