I

 

am the [Parent/Legal Guardian] of the minor child above, and have the power to consent to medical or dental treatment for [Him/Her]. I hereby voluntarily consent to authorize the medical staff and dental staff of Ibn Sina Foundation to provide health care services to the above minor. The health care services may include, but are not limited to , routine laboratory work, x-ray examinations/other imaging studies, anesthetic treatment, administration of medication, as well as procedures and treatments prescribed by the medical or dental staff. No prior determination of life-threatening emergency or danger of serious or permanent injury resulting from delay of treatment need be made under this authorization. The health care services may also include counseling services necessary to receive appropriate services including family planning services as defined by federal regulation.

I understand that there are no guarantees being made to me concerning the results of the treatment or the effectiveness of any birth control methods prescribed for the above minor.

I understand that this consent is valid and remains in effect as long as the minor is a patient of the clinic and I state that I have sufficient information, capacity, and authority to give this consent.

Submit