Patient Consent Form for Treatment

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.