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: _________________
Consent to Treat Minor, English