Consent for Treatment of a Minor

1. PATIENT INFORMATION

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2. PARENT/GUARDIAN INFORMATION

By signing below, I agree that being the parent or legal guardian of the patient listed above, give my consent for both emergency and routine medical and surgical treatment of this minor at the Health Center at Auraria should their condition so require it as deemed necessary by a Health Center at Auraria health care provider. I understand that in the case of an emergency, reasonable attempts would first be made to contact me, time and conditions permitting. As long as the medical or surgical treatment considered necessary in the situation, is in accordance with generally accepted standards of medical practice for the particular type of injury or illness involved, I impose no specific limitations or prohibitions regarding treatment other than those that follow: (if none, so state)

I understand that this authorization is good until the time in which the minor mentioned above reaches his/her 18th birthday.

By typing my full name below, I am electronically signing this document and acknowledge that this is a legal equivalent to my handwritten signature. By signing, I acknowledge that I have provided accurate information and agree to the terms and conditions of this document.