Consent for Treatment Consent for Treatment e-Form CONSENT FOR TREATMENT(Required) I understand and agree to the following authorization.I authorize that the following person(s) may bring my child(ren) for treatment with Dr. Porter and/or Dr. Galloway. I understand that ANYONE NOT LISTED BELOW MAY NOT BRING MY CHILD for treatment without a parent or legal guardian present. I understand that I will be required in the future to provide written consent before my child arrives for an appointment with someone other than a parent/legal guardian or person listed below. Signature of Parent/Guardian(Required) Today's Date(Required) MM slash DD slash YYYY Children Covered Within This Consent(Required)Child's Full nameDate of Birth Add RemoveComplete information for ALL persons authorized to bring your child(ren) to our office for treatment. All information must be completed in order for this consent to be valid.#1. Authorized Person First Last PhoneDriver's License # Relationship to Child #2. Authorized Person First Last PhoneDriver's License # Relationship to Child #3. Authorized Person First Last PhoneDriver's License # Relationship to Child
