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
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         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: _____ / _____ /______
or
_______(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