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 who is 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 Dr. Porter's office with written authorization before my child arrives for an appointment with someone other than a parent/legal guardian or any 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 RemoveAll requested information must be completed for each authorized person 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
