YOUTH CARE

YOUTH CARE
SAME DAY CARE	William W. Barnes, M.D., F.A.A.P.
Consent To Treat Minor

To Whom It May Concern:

In the event of a medical emergency, it is my/our desire, parent(s) of

that he/she/they be treated as deemed

necessary by licensed medical personnel selected as by .

I/we hereby authorize to designate

the physician or physicians and/or the medical institution (hospital) to initiate and medical treatment

deemed necessary for .

I/we realize that every effort will be made to contact us at the earliest convenience and it is my/our desire by this letter of authorization that medical treatment not be delayed by the inability to contact us first.

I/we accept full financial responsibility for all medical and health care rendered in response to this letter of authorization.

Name______________________ Name_____________________

Relation____________________ Relation____________________

Address____________________ Address____________________

Date______________________ Date______________________

Parent Signature_____________________

Notary Public

Subscribed and sworn to me this date:

My commission expires:

525 E. Blue Starr Drive

Claremore, Oklahoma 74017

Telephone: (918) 341-4311 Fax: (918) 341-8189