Pediatric Clinic de Chino Hills
15944 Los Serranos Country Club Dr. Suite 160, Chino Hills, CA 91709
Tel: (909) 606-8893; Fax: (909) 606-8828
Consent to Treat Minor in Absence of Parent /Guardian
Name of minor patient: _________________________ Date of Birth: _______________
I certify that I am the parent
and/or legal guardian of _________________________ (Name the minor patient)
I authorize ____________________________________ (name of person bringing child to the office) to bring my child to office visit with
Doctor HUA BAI, M.D. I consent to the examination and/or treatment of my child, including X-ray, laboratory tests, injection and immunizations.
I also agree to be financially responsible for the cost of such care.
_______(check) This authorization is limited to the following date: _____ / _____ /______
_______(check) This authorization is effective until revoked by me in writing.
Parent/Legal Guardian Contact Information:
Home phone# _____________ Office phone# ____________ Cell phone# ____________
Parent/Guardian Signature: ___________________________ Date: _________________
Witness Signature (in the office) ________________________ Date: _________________