Child Name:

Birth Date:

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Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Work Phone:


Parental Consent:

I hereby consent to any medical care and the administration of anesthesia determined by a physician to be necessary for the welfare of my child while said child is under the care of:
Name:

Relationship:

Name:

Relationship:

This authorization is effective from:

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to

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.
YesNo