PH 470.282.5729 | FAX 770.674.5795

6470 East Johns Crossing, Suite 200

Johns Creek, GA 30097

 

Herbert Alexander, MD   Paola Bonaccorsi, MDDale Sarradet, MD 

Consent to Treat a Minor without a Parent or Legal Guardian Present

By law, any child under the age of 18 years old cannot be seen by a doctor without consent from a parent or legal guardian. If the minor arrives with someone other than a parent or legal guardian, we must have written permission from the parent or legal guardian that this person has been appointed by you to act on your behalf.

For those occasions when you may not be with your child, please list those individuals who may give us consent to see your child:

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I have read and fully understand this consent for treatment. By signing below, I consent to medical treatment. This consent will remain valid and enforceable until it is revoked (canceled) or replaced by a new form of consent.

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