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